Disclosure De-prescribing: Reducing I have no relevant financial - PDF document

Disclosure De-prescribing: Reducing I have no relevant financial relationships with any Inappropriate Medications companies related to the content of this course. in Older Adults Anna H. Chodos, M.D., M.P.H. 2/19/2020 Overview Polypharmacy or Inappropriate Medications in Older Adults  Why is polypharmacy bad and what is  Polypharmacy: more than 5 or more than 10 meds deprescribing?  Almost 20% of community-dwelling adults >65 yo take 10 or more medications  Adverse drug events affect 5-35% of community-dwelling  Clinical tools for deprescribing adults >65 yo per year  Adverse drug events are responsible for ~10% of hospital admissions in older adults  Resources Patterns of medication use in the United States, 2006. http://www.bu.edu/slone/SloneSurvey/AnnualRpt /SloneSurveyWebReport2006.pdf Many of these slides are courtesy of Mike Steinman , Professor, UCSF Chrischilles, JAGS, 2007; Field, JAGS, 2004; Gurwitz, JAMA, 2003. Presentation Title 3 1 | [footer text here]

Deprescribing Problems with Polypharmacy = remove a med (or dose)  Non-adherence  Cost (higher with less insurance), schedule  Falls “Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a health care  Weight loss professional with the goal of managing polypharmacy and  Med-med interactions and adverse drug improving outcomes.” events - Increase risk of adv drug event 7-25% with each - Focus on individual medications (e.g. benzodiazepines) drug added - Focus on reducing # of medications  Cognitive decline  Mortality Agostini, JAGS, 2004; Magaziner, J Aging Health 1989; Larson, Ann Reeve, Br J Clin Pharmacol 2015. Int Med, 1987; Gurwitz, Polypharmacy, 2004. Division of Geriatrics Deprescribing: be proactive! What interferes the most in your ability to deprescribe? Inappropriate medications in older adults  Harms > benefits 1. Not enough time to review meds - Unnecessary, ineffective, potentially or actually harmful, not goal- 2. Inertia: harder to stop than to NOT start a med concordant 3. Other MDs prescribe meds that I don’t want to  Older adults need deprescribing- this should be an active stop concern 4. Not sure what is appropriate vs inappropriate - 50-60% use ≥ 1 med ineffective, not indicated, or duplicative 5. Don’t have bandwidth to work with patients on - 20-30% take ≥ 1 med to avoid in older adults (Beers, STOPP) tapers or discontinuation plan - 40-50% taking PPIs have no discernible indication 6. Patients don’t want to stop their meds Opondo PLoS One 2012; Wallerstedt Pharmacoepi Drug Saf 2016; Steinman JAGS 2007; Rossi Am J Geriatr Pharmacother 2007 Division of Geriatrics 8 Division of Geriatrics January 2017 2 | [footer text here]

Relational or emotional reasons: how we frame Why don’t we do better? discontinuation What you say: Patient may experience:  Practical barriers  Your Hemoglobin A1c is 7.2. There is no benefit to being that - Workflow & awareness low, so let’s stop your glipizide. Cognitive dissonance - Time & effort Fear of change  The zolpidem you are taking - Coordination with other clinicians Bad prior experience increases your risk of falling – - Patient education/support throughout the and studies show it actually Trust doesn’t help much with sleep. I discontinuation process Abandonment think we should stop it. Treatment (prescribing a medication) IS caring for a patient, right? Anderson BMJ Open 2015; Clyne Br J Gen Pract 2017 Reeve Br J Gen Pract 2016; Nicosia JGIM 2019 Division of Geriatrics Division of Geriatrics Oh, Canada Where is there evidence? Settings  Nursing homes – best evidence - Polypharmacy + potentially inappropriate meds  Mortality: OR 0.74 (0.65 – 0.84)  Falls: OR 0.76 (0.62-0.93)  Hospitalization: OR 0.64 (0.30 – 1.39)  Ambulatory care and hospital settings - Highly variable; limited quality and quantity of evidence Thilllainadesan Drugs Aging 2018; Kua J Amer Med Dir Assoc 2019 Division of Geriatrics 12 Division of Geriatrics January 2017 3 | [footer text here]

Not focused on physician  D-PRESCRIBE Trial  Community pharmacies  Age >65, chronic benzodiazepines, glyburide, chronic NSAIDs  Booklet - Education - Questions to induce cognitive dissonance, peer champion stories to increase self-efficacy, alternative treatments, practical advice (tapering schedules)  Pharmacists - Evidence-based pharmaceutical opinion to physicians www.deprescribingnetwork.ca/patient-handouts/ Martin JAMA 2018 Division of Geriatrics Division of Geriatrics Tools I use to Deprescribe 1. The Beers List 2. START/STOPP 3. Deprescribing.org 4. Anticholinergic Burden Calculator 5. MedStopper 6. A pharmacist 7. A letter from the insurance plan www.deprescribingnetwork.ca/pharmaceutical-opinions Division of Geriatrics 16 Presentation Title 4 | [footer text here]

Practical approach to deprescribing Practical algorithm for deprescribing Step 1: Comprehensive  Brown bag review: patient medication history brings EVERYTHING they are taking in to their visit in a “brown bag” - Every visit? - Arrange a separate visit - Prioritize at beginning of visit - Pharmacists Scott JAMA Intern Med 2015; Reeve Br J Clin Pharmacol 2014 Division of Geriatrics Division of Geriatrics Practical algorithm for deprescribing Practical algorithm for deprescribing Provider Step 1: Comprehensive medication history  Drugs-to-avoid criteria (Beers, Step 1: Comprehensive Patient medication history STOPP) Step 2: Identify potentially  Meds causing adverse effects (ask) inappropriate medications Step 2: Identify potentially - Benzodiazepines & “Z-drugs”  Difficulty with adherence inappropriate medications - Anticholinergics  Financial toxicity  Over-aggressive control: e.g. DM,  “Don’t like” HTN  Medications without indication: is there a problem that is on the list that this is treating?  Medications treating side effects of other meds (prescribing cascade)  Meds for stable symptoms Division of Geriatrics Division of Geriatrics 5 | [footer text here]

Practical algorithm for deprescribing Practical algorithm for deprescribing Step 1: Comprehensive  Patient willingness Step 1: Comprehensive  Proper timing medication history medication history - Listen! - Need to be able to determine if Step 2: Identify potentially Step 2: Identify potentially withdrawal reaction - “Forever” decision  reassure that can inappropriate medications inappropriate medications restart at any time - One drug at a time - Giving up  frame as optimizing attentive Step 3: Determine if med Step 3: Determine if med  Record what you do so you can care; think colonoscopy can be ceased, and can be ceased, and decide in the future prioritization prioritization - Adverse drug withdrawal effects  slow taper, monitoring plan - Proceed when the patient is on board Division of Geriatrics Division of Geriatrics Practical algorithm for deprescribing Practical algorithm for deprescribing Step 1: Comprehensive  Plan taper if necessary Step 1: Comprehensive  Monitoring & support medication history medication history - Prevent withdrawal reactions - Telephone Step 2: Identify potentially Step 2: Identify potentially - Early detection of re-emergence - Nurses, pharmacists, family inappropriate medications inappropriate medications  Symptom action plan  Document outcome Step 3: Determine if med can Step 3: Determine if med can  Rule of thumb – if requires tapering be ceased, and prioritization be ceased, and prioritization up of dose, will need taper down Step 4: Plan and initiate Step 4: Plan and initiate - CNS meds, opioids withdrawal withdrawal - Some exceptions: PPIs, clonidine, etc. Step 5: Monitoring, support, and documentation Division of Geriatrics Division of Geriatrics 6 | [footer text here]

Resources  Deprescribing is a team sport - Pharmacists, nurses, patient’s support system  Canadian Deprescribing Network (CaDeN) - www.deprescribing.org - Benzodiazepine receptor agonists - PPIs - Antipsychotics - Antihyperglycemics - Cholinesterase inhibitors and memantine Division of Geriatrics Division of Geriatrics Check them out! The Beers List • START/STOPP • Anticholinergic Burden • Calculator http://anticholinergicscales.es/ MedStopper • Division of Geriatrics 28 Presentation Title 7 | [footer text here]

If it’s not doing any harm then it’s ok to Don’t do that. leave a medication on. 1. True If it’s not benefitting someone, then it is only causing harm. (Polypharmacy in 2. False and of itself is harmful.) 29 Presentation Title 30 Presentation Title Case Case: His Meds at brown bag review  furosemide 20  albuterol 2 puffs Q4h PRN  torsemide 150 QHS  Benadryl PRN (OTC)  84yo M w/ CHF, CKD, h/o distal aortic  lisinopril 40  Temazepam 7.5mg QHS  diltiazem 120  colace 2 cap BID dissection with large intra-aortic stent,  metoprolol 100 XL BID  MVI (NOT ON MED LIST)  digoxin 0.125  KCL 8Meq BID. HTN, afib, DM, HLD, CAD/equiv, BPH s/p  imdur 30 QD  Recently discontinued: trazodone 50mg QHS (not effective) TURP x2, gout, COPD, insomnia, inguinal  clonidine 0.1mg BID  coumadin hernia, OA.  asa 81 daily  rosuvastatin 20  C/o fatigue and difficulty sleeping from  glipizide 10 BID  acarbose 50 TID AC neck pain. Also “unsteady”.  finasteride 5  terazosin 5  Exam: BP 88/47, HR 56  allopurinol 300mg  combivent 2 puffs QID 8 | [footer text here]