Deprescribing: with any corporate organization offering financial A - PDF document

1/24/2018 Disclosure Statement • I do not have (nor does any immediate family member have) a vested interest in or affiliation Deprescribing: with any corporate organization offering financial A Practical Approach support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation. Michael A. Biddle, Jr., PharmD, BCPS Clinical Assistant Professor of Pharmacy Practice Idaho State University College of Pharmacy Objectives • Review strategies, tools and materials to assist patients with deprescribing Pre-Test • Identify common medications that can be deprescribed • Choose an appropriate strategy for safe discontinuation of common medications Question #1 Question #2 Dan is a 80-year-old male patient a past medical history of a stroke (2 years), type Marge is an 74-year-old woman with the following medications: 2 diabetes (40 years), and high blood pressure (30 years). He takes the following • Amlodipine 5mg 1 tablet by mouth once daily for blood pressure medications: • Atorvastatin 20mg 1 tablet by mouth once daily for primary prevention of  Rosuvastatin 20mg 1 tablet by mouth daily ASCVD  Fenofibrate 145mg 1 tablet by mouth daily • Omeprazole 20mg 1 tablet by mouth once daily for heartburn  Metformin 500mg 2 tablets by mouth twice daily Levothyroxine 75 mcg 1 tablet by mouth once daily for hypothyroidism •  Aspirin 81mg 1 tablet by mouth daily • Alendronate 70mg 1 tablet by mouth once weekly for osteopenia  Lisinopril 20mg 1 tablet by mouth once daily • Alprazolam 0.25mg 1 tablet by mouth at bedtime as needed for insomnia Vitals & Labs (today): BP 132/78mmHg, HR 70bpm, RR 10rpm, Ht 5’10”, Wt 154lbs Using the website Medstopper.com, which medication would have the highest Lipid Panel CMP Reference Range stopping priority? TC 146 mg/dL Na 136 mEq/L 133-145 mEq/L TG 140 mg/dL K 4.5 mEq/L 3.3-5.1 mEq/L LDL 68 mg/dL Cl 105 mEq/L 96-108 mEq/L HDL 50 mg/dL CO2 22 mEq/L 20-29 mEq/L What medication could you BUN 15 mg/dL 7-20 mg/dL recommend for Dan to discontinue? SCr 0.5 mg/dL 0.5-1.2 mg/dL Glucose 126 mg/dL 74-100 mg/dL AST 24 U/L 10-40 U/L ALT 43 U/L 7-56 U/L A1c 6.8% 4-5.6% 1

1/24/2018 Question #3 Which of the following medications do NOT need to be tapered to prevent a discontinuation syndrome? A. Omeprazole Deprescribing Overview B. Diazepam C. Atorvastatin D. Metoprolol succinate E. Alendronate Defining Deprescribing Deprescribing Process • “Systematic process of identifying and discontinuing 1. Obtain a complete medication list with drugs in instances in which existing or potential harms indications for each medication outweigh existing or potential benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values and 2. Assess each medication for the risk of drug- preferences.” induced harm - Scott IA, et al. 3. Evaluate the appropriateness of each medication • “The process of withdrawal of an inappropriate medication, supervised by a health care professional 4. Prioritize drugs for discontinuation with the goal of managing polypharmacy and improving outcomes” 5. Implement a discontinuation plan and -Reeve E, et al. monitor the patient’s progress Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015:175:827-34. Reeve E, Gnjidic D, Long J, et al. A systematic review of the emerging definition of ‘ deprescribing ’ with netowrk analysis: implications Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. for future research and clinical practice. Br J Clin Pharmacol . 2015;80:1254-68 2015:175:827-34. Deprescribing Algorithm Safety Concerns of Deprescribing • Adverse drug withdrawal events • Physiological reactions to withdrawal • Associated with corticosteroids, CNS agents and PPIs • Can be prevented by tapering but could still occur during the taper • Serious harm is rare Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older adults and strategies to 2015:175:827-34. mitigate potential harms. Expert Opin Drug Saf. 2018;17:39-49. 2

1/24/2018 Safety Concerns of Deprescribing Safety Concerns of Deprescribing • Return of medical condition • Reversal of drug-drug interactions • Prevalence of return varies between conditions • Limited research in this area • Close monitoring can minimize the consequences • Consider pharmacokinetic and pharmacodynamic implications of drugs being discontinued • Restarting the discontinued medication can revert • Enzyme inducers or inhibitors symptoms to baseline • Effects on drugs with narrow therapeutic indexes • Deprescribing preventative medications can be more challenging due to difficulty in monitoring • Difficult to know if breaks in therapy will have long term effects Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older adults and strategies to Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2018;17:39-49. mitigate potential harms. Expert Opin Drug Saf. 2018;17:39-49. Barriers to Deprescribing Barriers to Deprescribing • Patient Barriers • Provider Barriers • Concern about contradicting a specialist’s recommendation • Fear of the condition worsening or returning • Fear of causing withdrawal symptoms or disease relapse • Previous negative experience with deprescribing • Lack of data to assess risks and benefits with older patients • Influence from friends, family, etc. • Worry that discussing life expectancy and deprescribing may be • Hope of future effectiveness interpreted as a reduction in care • Pressure from guideline recommendations • Addressing Barriers • Limited time to discuss discontinuation • Include the patient and caregivers in the process • Addressing Barriers • Shared decision making • Work as as team to develop a collaborative, patient-centered plan • Provide education about risks and benefits • Clearly communicate with all providers involved in the patient’s care • Provide a clear plan that includes managing withdrawal symptoms • Include patient-specific factors and evidence-based risk/benefit assessments to support deprescribing decisions • Provide ongoing support and monitoring to reassure the • When available, use evidence-based deprescribing guidelines and patient and caregivers algorithms Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015:175:827-34. 2015:175:827-34. Bemben NM. Deprescribing: An application to medication management in older adults. Pharmacotherapy . 2016;36:774-780. Deprescribing Through Shared Decision Making • Step 1: Creating awareness that options exist Deprescribing Tools • Step 2: Discussing the options and their benefits and harms • Step 3: Exploring patient preferences for the different options • Step 4: Making the decision Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ . 2016;353:i2893. 3