Page 36 - Christiana Care Focus February 2019

Pharmacy Services |
Deprescribing in older adults
Polypharmacy, the use of multiple medications that may be unnecessary, is prevalent among older adults. Studies show that over 30 percent of patients 65 and older are prescribed five or more drugs, placing them at increased risk of drug-drug interactions, drug-disease interactions, adverse drug events and medication nonadherence. Additionally, polypharmacy in older patients is associated with functional impairment and increased costs, and is an indicator of increased morbidity and mortality.
Deprescribing involves identifying inappropriate or unnecessary medications and tapering or discontinuing them with the goal
Connie Y. Shah, Pharm.D., BCPS, BCGP
of minimizing adverse consequences of polypharmacy while ensuring that patients continue to receive appropriate therapy. This process is part of the prescribing continuum, which includes medication initiation, dose titration, changing or adding drugs, and stopping therapy. Similar to prescribing principles used during drug initiation, deprescribing is a patient-focused intervention that requires shared decision-making, patient consent, and close monitoring.
Deprescribing may be implemented using a systematic process that generally involves the steps outlined below.
DEPRESCRIBING PROTOCOL FOR PROVIDERS
Compile a comprehensive medication history
• Obtain an accurate list of all routine, as needed, and intermittent medications including prescription drugs, over-the-counter medications and supplements.
• Document the indication for each medication.
• Ask the patient whether there are any regularly prescribed medications that are not being taken (and if so, why not).
• Identify possible adverse drug reactions.
Consider the overall risk of drug-induced harm
• Assess risk according to drug factors: total number of drugs, use of potentially inappropriate drugs (i.e., Beers Criteria) or high-risk drugs (e.g. benzodiazepines, opioids), adverse effects.
• Assess risk according to patient-specific factors: age, degree of cognitive impairment, comorbidities, presence of geriatric syndromes (falls, delirium, weight loss), nonadherence.
Assess each medication for its eligibility to be discontinued
• Criteria for discontinuation include: medications that lack a valid indication, are a result of prescribing cascade, fail to control disease/symptom, disease/symptom has resolved, or if the patient’s life expectancy exceeds the time-to-therapeutic benefit for preventive medications (e.g., statins, bisphosphonates).
• Consider whether the patient would like to stop any medications because of adverse effects or complex dosing regimens.
Prioritize medications for discontinuation
• The order of discontinuation depends on the following criteria:
1. Drugs with the greatest harm and least benefit.
2. Drugs that are easiest to discontinue with low likelihood of withdrawal or disease rebound.
3. Drugs that the patient is most willing to discontinue first.
• Rank drugs from those with high harm and low benefit to those with low harm and high benefit, and then discontinue sequentially as appropriate.
Implement and monitor medication discontinuation
• Discontinue one medication at a time so that potential harms (such as withdrawal or rebound of disease) and benefits (resolution of adverse effects) can be attributed to specific medications and addressed if needed.
34 CHRISTIANA CARE HEALTH SYSTEM
Therapeutic Notes