When Less is More: Deprescribing Medications

Transcription

1 When Less is More: Deprescribing Medications Robert B. Allison, II DO March 2, 2019 PDescribe polypharmacy, the individals at risk, and the potential adverse drg events related to mltiple medications OBJECTIVES PReview deprescribing myths and pitfalls PRecognize common medications that can be deprescribed PApply deprescribing algorithms for clinical se 1

2 POLYPHARMACY DEFINING POLYPHARMACY Explain left vs right 2

3 DEFINING POLYPHARMACY Concrrent se of mltiple medications American Jornal of Medicine 1985 The se of two or more medications - Drgs & Aging 2010 Polypharmacy was defined as the concrrent se of five or more medications Crrent Gerontology and Geriatrics Research 2017 POLYPHARMACY Mltiple medications for adlts 65 years old 40% take 5 to 9 medications 18% take 10 + Adverse Drg Events (ADE) occr becase of: Age-related physiological changes a greater degree of frailty Mltimorbidity Polypharmacy Emergency Hospitalizations for Adverse Drg Events in Older Americans NEMJ

4 Adverse Drg Events Adverse drg events are a direct conseqence of clinical care Older adlts are 7 times more likely to have adverse drg event than yonger patients Adverse Drg Events Emergency Hospitalizations for Adverse Drg Events in Older Americans NEMJ

5 Adverse Drg Events Emergency Hospitalizations for Adverse Drg Events in Older Americans NEMJ 2011 Adverse Drg Events Most Commonly Implicated Medications Reslting in Hospitalizations: ü Warfarin (33.3%) ü Inslins (14%) ü Oral Anti-platelet Agents (13%) ü Oral Hypoglycemics (11%) ü Opioid analgesics (4.8%) ü Antibiotics (4.2%) ü Digoxin (3.5%) ü Antineoplastic agents (3.3%) Emergency Hospitalizations for Adverse Drg Events in Older Americans NEMJ

6 DEPRESCRIBING MYTHS AND PITFALLS PROVIDER CENTERED MYTHS PATIENT CENTERED It can come off looking like yo no longer care abot the patient, yo know, Yo re old enogh to die now so it doesn t really matter We need more research, more collaborations Edcation wold be very helpfl for s, in sort of jst giving s more confidence The reason yo don t stop things is yo think they [specialists] know better than yo There are people who see medication as the barrier between them and the grave a pill for every ill Yo need some fnded time with the patient so that yo can bring the patient in and say This is a special appointment that s not to talk abot yor crrent medical problems, it s specifically abot managing yor medicines better. Swimming against the tide. Ann Fam Med

7 PITFALLS Medication management and prescribing has been a cornerstone of medicine from it s inception Deprescribing is not commonly taght, it s time-consming, and it can come with inherent risks for both providers and for their patients Physicians want to maintain a relationships with both their patients and colleages In some cases, polypharmacy is not synonymos with inappropriate treatment. In several cases, a mlti-drg regimen is necessary and appropriate DEPRESCRIBING 7

8 DEPRESCRIBING 1/5 medications commonly taken by older adlts may be inappropriate 1/3 prescriptions may be inappropriately sed for those living in managed care facilities The NUMBER of drgs a patient takes is the single most important predictor of harm What is DEPRESCRIBING A systematic process of identifying and discontining drgs when existing or potential harms otweigh existing or potential benefits based on the patient s: Goals of Care Crrent Level of Fnctioning Life Expectancy, Vales Preferences Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med

9 THE PRESCRIBING CONTINUUM Therapy Initiation Dose Titration Changing or Adding Drgs Deprescribing Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med DEPRESCRIBING Deprescribing is not abot denying effective treatment to eligible patients. It is a positive, patient-centered intervention, with inherent ncertainties, and reqires shared decision making, informed patient consent, and close monitoring of effects Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med

10 DEPRESCRIBING The Process of deprescribing involves: Diagnosing a problem (se of a potentially inappropriate medication) Making a therapetic decision (withdrawing medication with close follow-p) Altering the natral tendencies of providers in an attempt to redce the incidence of drg-related adverse events q Falls q Relieving adverse effects q Improving fnction q Preventing prematre death THE 5 STEPS OF DEPRESCRIBING 1. Reconcile all the medications and the reason for each medication P Prescription P OTC P Spplements 2. Determine the overall harm the medication list poses to the patient P Nmber of pills P Patient age P Life expectancy / comorbidities P Adherence / cognitive fnction Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med

11 THE 5 STEPS OF DEPRESCRIBING 3. Assess each drg for it s ability to be deprescribed P No VALID indication P Part of a deprescribing cascade / taper P ADE > potential benefit - Side effect effect P Frther need / effectiveness P Preventive effect nlikely to confer any patient-oriented benefit based on life expectancy P Goals of care / patient preference P Drgs are imposing nacceptable treatment brden Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med THE 5 STEPS OF DEPRESCRIBING 4. Prioritize the deprescribing P P P Drgs with greatest harm and least benefit Drgs easiest to discontine Pills the patient is most willing to discontine first Low harm, high benefit intermediate harm, moderate benefit High harm, low benefit Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med

12 EXAMPLES OF DRUGS TO BE DEPRESCRIBED Prescriber Ease of Removal q Mlti-vitamins q Iron Spplements q Vitamins q Spplements q Proton Pmp Inhibitors q Oral hypoglycemics q Acetylcholinesterase Inhibitors q Antihypertensive q Opioids q Benzodiazepines q Antipsychotics Patient Resistance of Removal p Opioids p Benzodiazepines p Acetylcholinesterase Inhibitors p Vitamins p Spplements p Antipsychotics p Oral hypoglycemics p Antihypertensive p PPI p Iron Spplements THE 5 STEPS OF DEPRESCRIBING 5. Implement and monitor deprescribing regimen P Develop a management regimen between prescriber and patient P Stop 1 mediation at a time P Ween medications likely to case withdrawal effects P Docment the reasons for and otcomes of deprescribing Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med

13 Where s the Evidence??? The SPACE randomized clinical trial. JAMA

14 Vitamin D screening and spplementation in commnity-dwelling adlts. Am Fam Physician Most randomized clinical trials of vitamin and mineral spplements have not demonstrated clear benefits for primary or secondary prevention of chronic diseases not related to ntritional deficiency High doses of β-carotene, folic acid, vitamin E, or selenim may have harmfl effects, inclding increased mortality, cancer, and hemorrhagic stroke Mltivitamin/mltimineral spplementation is not recommended for generally healthy adlts Cocoa Spplement and Mltivitamin Otcome Stdy (COSMOS) to conclde October 2020 Vitamin and mineral spplements: what clinicians need to know. JAMA

15 Case 1 67yo male with h/o HTN, HLD, DMII, BPH, and GERD presents for CDM. He states he wants to get off of some of his medications becase he jst retired, went on Medicare insrance, and fond ot they don t cover some of his old medications. Medications Chlorthalidone 50mg daily Lisinopril 20mg daily Metformin 1000mg BID Atorvastatin 40mg daily Glybride 10mg BID Detrol XL 4mg daily Nexim 40mg daily Aspirin 81mg daily Potassim Chloride 20meq BID Selenim daily Mltivitamin daily Case 1 He does report he has been trying to eat better, started walking with his wife at night, and has ct back on the alcohol since retiring. Unfortnately, he has been getting dizzy at night and finds that he is clammy when he wakes p to go to the bathroom. He has 3-4 episodes of noctria / night. He also finds that he s constipated. Otherwise, he denies any fevers, chills, CP, SOB, nasea, abdominal pain, diarrhea, constipation, or daytime rinary freqency. Exam Vitals: 112/72, HR 78, RR 12, 98.6 General: WD, WN, NAD HEENT: NC/AT, EOMI, PERRLA, Oral pharynx appears dry Cardiac: RRR, no M/R/G Lngs: CTA bilat, no W/R/R Abdomen: BS x 4, soft, NT/ND. No R/G/R Ext: No clbbing, cyanosis, or edema DRE: Appropriate sphincter tone, symmetrically enlarged prostate withot nodle 15

16 Case A1c: 5.9 PSA: 1.20 Case 1 How do we start with deprescribing? 1) Reconcile all the medications and the reason for each medication. 2) Determine the overall harm the medication list poses to the patient. 3) Assess each drg for it s ability to be deprescribed. 4) Prioritize the deprescribing. 5) Implement and monitor deprescribing regimen. 16

17 Case 1 Medications Chlorthalidone 50mg daily Lisinopril 20mg daily Metformin 1000mg BID Glybride 10mg BID Atorvastatin 40mg daily Tolterodine XL 4mg daily Esomeprazole 40mg daily Aspirin 81mg daily Potassim Chloride 20meq BID Selenim daily Mltivitamin daily Indications Hypertension Hypertension Diabetes Diabetes Hyperlipidemia Overactive Bladder? GERD no Barrett s or esophagitis Primary ASCVD prevention hypokalemia 2 to Chlorthalidone??????? Case 1 Medications P P P P P P P Chlorthalidone 50mg daily Lisinopril 20mg daily Metformin 1000mg BID Glybride 10mg BID Atorvastatin 40mg daily Tolterodine XL 4mg daily Esomeprazole 40mg daily Aspirin 81mg daily Potassim Chloride 20meq BID Selenim daily Mltivitamin daily Indications Hypertension Hypertension Diabetes Diabetes Hyperlipidemia Overactive Bladder? GERD no Barrett s or esophagitis Primary ASCVD prevention hypokalemia 2 to Chlorthalidone??????? 17

18 Case 1 Where do we start with deprescribing? Case 1 Assessment / Plan: 1. Diabetes Mellits well controlled. Likely getting hypoglycemic at night given tight glycemic control. Deprescribe Glybride. Contine Metformin. Recheck A1c 3mos 2. Hypertension contine lisinopril for primary and secondary prevention. Consider stopping chlorthalidone and potassim spplement given well controlled hypertension and hypokalemia on BMP. Repeat BMP 1wk 3. GERD No history of Barrett s or esophagitis. Consider deprescribing esomeprazole 4. BPH No indication for over-active bladder treatment. Pt also experiencing likely anticholinergic side effects from Detrol LA. Consider deprescribing tolterodine LA 5. Primary ASCVD prevention Contine atorvastatin and ASA. No indication for spplement se. Deprescribe mltivitamin and selenim 18

19 Other Deprescribing Tools PDescribe polypharmacy, the individals at risk, and the potential adverse drg events related to mltiple medications OBJECTIVES PReview deprescribing myths and pitfalls PRecognize common medications that can be deprescribed PApply deprescribing methods clinically 19

20 QUESTIONS? RESOURCES American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society 2015 pdated beers criteria for potentially inappropriate medication se in older adlts. JAGS American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adlts. JAGS Bdnitz, DS, et al. Emergency hospitalizations for adverse drg events in older americans. N Engl J Med 2011;365: Krebs, EE, et al. Pain-related fnction in patients with chronic back pain or hip or knee osteoarthritis pain. The SPACE randomized clinical trial. JAMA. 2018;319(9): LeFevre, ML, LeFevre, NM. Vitamin D screening and spplementation in commnity-dwelling adlts: common qestions and answers. Am Fam Physician. 2018;97(4): Mahony, D. et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Aging Mason, JE, Bassk, SS. Vitamin and mineral spplements: what clinicians need to know. JAMA (9): Moyer VA; US Preventive Services Task Force. Vitamin, mineral, and mltivitamin spplements for the primary prevention of cardiovasclar disease and cancer: US Preventive Services Task Force ecommendation statement. Ann Intern Med. 2014; 160(8): Scott, IA, et al. Redcing inappropriate polypharmacy the process of deprescribing. JAMA Inter Med. 2015;175(5): Vrettos, I, et al. Disease linked to polypharmacy in elderly patients. Crrent gerontology and geriatric research Wallis, KA. Swimming against the tide: primary care physicians views on deprescribing in everyday practice. Ann Fam Med 2017; 15(4):