Targeted Deprescribing in Patients on Hemodialysis to Decrease Polypharmacy

Targeted Deprescribing in Patients on Hemodialysis to Decrease Polypharmacy

Presentation Objectives Discuss Polypharmacy In HD patients Define Deprescribing Review results of the pilot study on deprescribing in our HD unit Discuss the goals of the CanSolve Study on Deprescribing.

Background Polypharmacy means many drugs - 5 or more drugs Polypharmacy also means inappropriate choices of medications or doses HD pts take an average of 15 medications/day Patterson et al. Cochrane Database Sys Rev 2012; Manley et al NDT 2004

Deprescribing The process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes Associated with fewer referrals to long-term care facilities, lower drug costs, decreased mortality Improvements in patient s perception of their global health. Thompson and Farrell Can J Hosp Pharm. (2013); 66(3): 201 202

Why Deprescribing in Hemodialysis? Hemodialysis patients have high pill burden Evidence for efficacy of many therapies is lacking in hemodialysis population Safety concerns for medications that are cleared by the kidney and not removed by hemodialysis No tools for deprescribing available for this population Chiu et al. Clin J Am SocNephrol. (2009);4(6):1089-96

Targeted Deprescribing in an Outpatient Hemodialysis Unit to Decrease Polypharmacy: A Pilot Study

Objectives 1. To develop deprescribing algorithms for target medications that have poor evidence for efficacy and safety in the HD population 2. To determine the effectiveness of these algorithms in decreasing polypharmacy when incorporated into current practice in the HD unit 3. To monitor patient safety and satisfaction throughout this initiative

Methods Phase 1: Development of Deprescribing Tool Literature search performed Focus groups were conducted Reviewed 50 charts to assess how common the selected medications were used Five target medications were selected based on poor evidence for patient safety and lack of evidence for efficacy

Five Targeted Medications Diuretics PPIs Quinine Alpha-blockers Statins** Medication specific algorithms were developed

Methods Phase 2: Validation of Deprescribing Tool Face and content validity was assessed through three repetitive cycles with the Nephrologists and Pharmacists.

Methods Phase 3: Implementation and Evaluation of Deprescribing Tool Prospective Observational Pilot Study Patients receiving HD at Toronto General Hospital between May 2014 and March 2015 were included

Methods-Phase 3 Implementation Collect BPMH, Identify Target Medication, Apply Algorithm, Inform Team, Consent Patient Communicate with patient the plan, monitor as per algorithm Follow up 6 months later BPMH-Best Possible Medication History

Methods Phase 3: Evaluation of Deprescribing Algorithm Primary endpoint: proportion of target medications successfully deprescribed Secondary endpoints: Average number of medications per patient before and after the intervention Proportion of successful deprescribing trials for each target medication Patient safety and satisfaction

RESULTS

Selection of Patients Figure 1: Flowchart of patient recruitment and participation Total HD patient population n=240 Approached n = 71 patients (80 target medications) Excluded (n = 169) -taking drug for valid indication (n=109) -not taking a target medication (n=60) - Excluded n=36 patients (40 target medications), see Table 3 Recruited n = 35 patients (40 target medications) Successfully deprescribed after monitoring period n= 27 (31 target medications) Successfully deprescribed after 6 months n=19 (25 target medications)

Baseline Characteristics Table 1: Baseline Characteristics Characteristic Total (n=35) Age (y) Mean + SD (Range) 65 + 16.5 (33-92) Gender 21 males, 14 females Dialysis Vintage (months) 40 (23.2, 57.2) Median Total Number of Medications 13.4 + 4.3 Mean + SD (Range) Comorbidities Hypertension 31 Diabetes Mellitus 21 Cardio Vascular Disease 21

Results - Endpoints Primary endpoint: 31/40 (77%) medications were successfully deprescribed. Secondary endpoints: The average number of medications per day decreased from 13.4 ± 4.3 to 12.7 ± 4.4 (n=35) after the deprescribing trial. Patient safety and satisfaction

Discussion Validate and implement a safe and practical tool to deprescribe 5 classes of drugs for HD patients Helped guide clinical practice Increased awareness of inappropriate medication use

Single center Limitations Patient may continue to use medication at home A new medication may be prescribed during deprescribing trial Did not follow long term clinical outcomes

Conclusion Feasible to incorporate this deprescribing tool in routine practice without added costs In routine practice, we perform BPMH in all patients and we monitored the parameters that were part of the deprescribing algorithm Increased patient safety Future Studies- implement as a RCT in more centres across Canada

CanSolve Overall Goal To improve current clinical practice by decreasing polypharmacy in the HD units across Canada. This will be achieved by developing deprescribing algorithms for medications that lack evidence for efficacy and safety in the HD population using a systematic national, evidence-informed consensus building process

CanSolve Objectives 1.To assess and compare demographic and medication use patterns in HD patients across Canada. 2.To develop new deprescribing algorithms and build upon current deprescribing algorithms for HD patients. 3.To establish consensus driven medication deprescribing algorithms that will be implemented and evaluated in clinical practice in HD units across Canada.

CanSolve Objectives 1.To assess and compare demographic and medication use patterns in HD patients across Canada. 2.To develop new deprescribing algorithms and build upon current deprescribing algorithms for HD patients. 3.To establish consensus driven medication deprescribing algorithms that will be implemented and evaluated in clinical practice in HD units across Canada.

Medication Use in Ontario 70% 60% 50% 40% 30% 20% 10% 0%

CanSolve Objectives 1.To assess and compare demographic and medication use patterns in HD patients across Canada. 2.To develop new deprescribing algorithms and build upon current deprescribing algorithms for HD patients. 3.To establish consensus driven medication deprescribing algorithms that will be implemented and evaluated in clinical practice in HD units across Canada.

Digital poll of top 12 drugs to de-prescribe 1.PPI 2.Allopurinol 3.Quinine 4.Diuretics 5.Alpha blockers 6.Benzodiazepines/hypnnotics 7.Statins 8.Anticonvulsants- gabapentin/pregablin 9.Prokinetics- metoclopramide/domperidone 10.TCAs (antidepressants) 11.Warfarin 12.Opioids

Algorithm Development 1.PPI 2.Allopurinol 3.Quinine 4.Diuretics 5.Alpha blockers 6.Benzodiazepines/hypnnotics 7.Statins 8.Anticonvulsants- gabapentin/pregablin 9.Prokinetics- metoclopramide/domperidone

Example of Algorithm-PPIs

Objectives 1.To assess and compare demographic and medication use patterns in HD patients across Canada. 2.To develop new deprescribing algorithms and build upon current deprescribing algorithms for HD patients. 3.To establish consensus driven medication deprescribing algorithms that will be implemented and evaluated in clinical practice in HD units across Canada.

Discussion/ Questions