DEPRESCRIBING: WAYS TO REDUCE POLYPHARMACY

Author: Scott Endsley, M.D., Associate Medical Director, Quality

As often defined, polypharmacy is the prescription of greater than 5 to 9 medications. Another definition focuses on medications that are prescribed without specific current indication or duplicates other medications, or is known to be ineffective for the condition being treated. Polypharmacy is highly prevalent, especially among older adults. A 2016 study found that 36% of community dwelling adults over 60 were taking five or more medications. This prevalence rate is increasing, up from 31% in 2005. At this rate of increase, almost half of the older population by 2030 will be affected by polypharmacy. Three to five percent of emergency department visits are for adverse drug events, and 37% of these get admitted.

However defined, polypharmacy has multiple adverse consequences for patients and for health systems. These include adverse drug events, medication non-adherence, increased mortality and cost, functional impairment. Perversely, polypharmacy can result as a cascade, started a medication that causes an adverse drug event which leads to new or additional treatment, and so on. The proverbial cat chasing its tail.

Medications have both potential beneficial AND negative consequences. For instance, delirium and worsening of dementia is common with the anticholinergics, benzodiazepines, and PPIs; falls are more common with patients on antihypertensives, antipsychotics, benzodiazepines and opioids; constipation is common with the opioids and calcium channel blockers; and orthostatis is common with anticholinergics, antihypertensives and sulphonylureas.

Deprescribing[1],[2] is a set of interventions to identify inappropriate or unnecessary medications and discontinuing them. In essence, it is backing off of care for the safety of the patient like taking your foot off the accelerator of medical therapy. Studies have suggested that deprescribing leads to improvement in cognition, fewer falls, and improved survival.[3] These interventions include:

  • Reviewing all current medications
  • Identifying medications to be discontinued, substituted or reduced
  • Planning the deprescribing process with the patient
  • Regular re-reviews of current medications.

Brown Bag Review. The first step in deprescribing is to have the patient bring ALL of their medications (including OTC medications and supplements i.e.vitamins, minerals) to a visit, and take a medication history. Determine which medications they are actively taking and on what regimen, and ask about potential side effects. Consider if these medications are offering benefit or causing harm.

Deprescribe Medications. With the patient, discuss the advantages of stopping specific medications in terms of avoidance of harms without loss of benefit for their health. Consider discontinuing one medication at a time, tapering if necessary, to monitor for worsening of condition or withdrawal effects. Start with considering medications that fall into the following categories:

Potentially inappropriate Anticholinergics, opioids, NSAIDS, drugs on the BEERS list
Lack efficacy Antihypertensives that aren’t working, SSRIs without mood improvement, oxybutynin without improvement in incontinence
Lack indication Diuretics for edema without CHF, PPI as prophylaxis, SSRI for resolved depression, antihypertensive for normotensive patients
Don’t provide additional benefit Statin or bisphosphonate in patient with limited life expectancy
Require long duration for effect Statins in low risk patients
Patient would like to stop Patient has had adverse effect from medication
Complex dosing regimens Multi-dose medications with once daily dosing available

There are a number of resources that are helpful in planning your deprescribing process such as:

  1. BEERS list- americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
  1. Deprescribing Guideline Resource Site – http://deprescribing.org/

Consider specific classes of medications and possible reasons to deprescribe. The following table is adapted from the McGrath article in Journal of Family Practe (Ref 2)

DRUG CLASS REASON TO DEPRESCRIBE
Statins High risk of myopathy, low cholesterol associated with increased mortality in older patients
Antihypertensives Hypotension, risk of falls, little benefit from aggressive lowering in older patients
Benzodiapezines Confusion and falls, NOT indicated for insomnia or long-term management of anxiety
Proton Pump Inhibitors Few long term indications, significant drug-drug interactions
NSAIDS/COX2/ASA Exacerbate CKD, ulcers, CHF

 

Planning Deprescribing with the Patient. Many patients will resist stopping medications, especially those on which they have been prescribed for a long time. This may come from concerns about their conditions worsening, or contradicting the original prescriber. The key in these discussions is a supportive discussion of the potential or real adverse effects of these medications, the potential benefits from deprescribing such as cognitive or functional gains, and the minimal (if at all) impact on their conditions. This latter is especially true for medications prescribed without clear indication or has had no significant clinical benefit. Emphasize that reducing polypharmacy can significantly change their risk of being hospitalized.

Regular Re-Review of Medications. As you deprescribe, this may require tapering so the process needs to be monitored closely. On at least an annual basis (some recommend a medication review at every visit), look closely at all medications again. Many of our patients see multiple providers and ‘accumulate’ medications across conditions that need to be closely monitored. Actively engage your specialist colleagues in discussions of benefits/harms and options of new medications.

[1] Scott IA, Hilmer SN, Reeve E, et al.,”Reducing inappropriate polypharmacy: the process of deprescribing”. JAMA Internal Medicine. 2015; 175:827-834

[2] McGrathK, Hajjar ER, Kumar C, et al. “Deprescribing: a simple method of reducing polypharmacy”, Journal of Family Practice,. 2017; 66(7): 436-445

[3] Pager AT, Clifford RM, Potter K, et al. “The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis”, British Journal of Clinical Pharmacology, 2016; 82:583-623

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