282018Aug

Consider “Deprescribing”: Three Important Steps

Deprescribing refers to the process of discontinuing the usage of an inappropriate or unnecessary medication.

Patients are often prescribed a medication for a legitimate ongoing medical conditions, but with no intent of using that medication for the remainder of their lifetime. The purpose of de-prescribing is to manage polypharmacy and improve health outcomes.

Some people outgrow their medications. Diet and lifestyle modifications can improve or even completely resolve some conditions, making the usage of chronic medications no longer necessary for symptom control. The aging process also causes the kidneys and liver to be less efficient metabolizing certain medications, which may necessitate a dosage reduction, change in therapy, or complete discontinuation in order to reduce the risk of an adverse drug event.

According to Carrie Schanen, KHP Managed Care Pharmacist, “The more medications a person takes, the greater the risk of them having an adverse drug event. This is particularly important for elderly patients as a significant number of hospital stays among older adults are attributed to drug-related complications.”

Deprescribing should be a shared decision-making process between the provider and patient or their caregiver.

  1. The first step should always include a comprehensive medication history including:  assessment of the patient’s adherence to their medications; overall risks and benefits depending on individual patient factors, including life expectancy, cognitive and functional factors, and impairments the medications may be causing (i.e. increased fall risk or impaired cognition); drug related factors, including daily pill burden, complexity of medication regimens, and potential drug-drug interactions.
  2. Determine which medications are most important to the patient, identify potentially inappropriate medications with no specific indication (due to the condition being resolved or uncertainty as to why initially prescribed), medications with questionable efficacy, and those with increased risk of interactions.
  3. Consider whether abrupt discontinuation of the medication is known to cause withdrawal symptoms, and if so ensure a slow dose reduction is made. This is common among many hypertensives, antidepressants, anxiolytics, and pain medications. When a slow dose reduction is required, include specific documentation on the tapering plan and ensure that clear communication is provided to the patient, their caregivers, and other clinicians.

Consider deprescribing these common classes of medications:

  • NSAIDS – These agents can increase the risk of bleeding stomach ulcers. They can also increase blood pressure, negatively impact kidney function, and worsen heart failure.
  • Muscle Relaxants – These agents can increase fall risk, impair cognitive function, and cause anticholinergic effects such as dry mouth, urinary retention, and constipation.
  • Benzodiazepines – These anti-anxiety agents can contribute to cognitive impairment, delirium, falls and other related injuries.
  • Sedative Hypnotics – Commonly prescribed for insomnia, chronic usage should be avoided due to an increased risk of delirium, falls, fractures, and impaired cognition.
  • Tricyclic Antidepressants – Although not recommended, these are often used for dementia in the elderly and can cause low blood pressure resulting in falls and fractures, heart arrhythmias, delirium, urinary retention, dry mouth, and constipation.
  • Proton Pump Inhibitors – Long term usage may result in increased fracture risk and hypomagnesemia. These agents also have several significant drug interactions due to reducing the oral bioavailability for drugs that require an acidic environment for absorption.