Deprescribing

It has been 3 weeks since I am in a geriatric consultation rotation and I realized that medication is a major topic, in fact an every consultation topic.

The Pharmacist of the Hospital gave us a pretty good talk about deprescribing older adults. Also, at this month Geriatric committee, we heard about a great program: Pharmacist at home. A Pharmacist, at the request of the geriatric team, go into the house of our elders, review all the current prescriptions, adverse effects, indications, review all the alternatives/vitamins medication, remove what is out of date from the pharmacy and explain every medication to the patient. This is GREAT!

It hit me! Let’s talk about medication.

First, let’s review the definition of polypharmacy. Although it is a common topic, there is no clear consensus on the definition. Some would argue that 5 or more, others 6 or more. Let’s say multiple medications use. One thing to remember is that polypharmacy is not always a bad thing. Let’s say a person has 4-5 comorbidities (ex: ACS, BPH, HTN, Diabetes), then taking 4-5 medication would be a good thing! Polypharmacy becomes a bad thing when inappropriate or non indicated medications are used.

The consequences of multiple medications use can be important(1):

  • Increase interactions
  • Decrease compliance which could lead to poorer outcomes
  • Increase adverse effects
  • Increase cost
  • Cascade of prescription

As patients get older, we should objectively reassess every medication once in a while because although it was indicated at the age of 50, maybe that at 75 years old the goal of care has changed and this medication is no longer indicated. This is actually a recommendation from the Canadian Medical Association.

But how do we deprescribe? I read this very interesting paper published in the CMAJ in 2014 entitled “Deprescribing for older patients” (2). It is a very straightforward review. Here are some of the unlighted concepts:

  • When deprescribing? Pretty much whenever you have the chance. While you see a patient for a routine follow up, evaluating a patient in the ED after a fall, at admission, at discharge, etc. Just do it!
  • Review every indication and ask yourself if it aligns with the goal of care. Think more universally than it terms of disease. For example: the goal of care might be to reduce dizziness/orthostatic that can lead to fall instead of lowering the blood pressure to reduce the risk of stroke.
  • A review of the literature seems to advocate that it might be helpful to deprescribe without being harmful. But evidences are thin.
  • My personal favourite: A Cochrane review stated that the alliance of a Pharmacist with a Physician results in a substantial reduction of inappropriate prescribing (3).

Sometimes the goals of care are still disease-targeted. The other question is what are the targets for geriatrics?

GOOD question. About targeted blood pressure, Hypertension Canada would recommend to tolerate a systolic of 150 for elderly. For diabetics, HbA1c of less than 8.5% would be acceptable for frail elderly (normally <7% for general diabetic population). As for hyperlipidemia, studies have a tendency to include very few patients over 75 years old, so no precise target for our older adults.

Knowing all of this, is there a guidelines about appropriate medication for elderly. Here are a few resources that everyone can use:

  • Beers criteria: It is a list of drugs by class of medication from a consensus of expert panel about concerning medication for geriatric care. Very user friendly, but my modest opinion, almost every common medication is on this list (and a lot that we do not use anymore!). It is helpful for sure but it is a tool, not a rule.
  • STOPP criteria: 65 items by class of system and inappropriate medication
  • START criteria: 22 items for each system and appropriate medication
  • Choosingwisely.org: 10 recommendations about geriatrics that we should all know, some of them about medication.

But how should we do it? This is why a pharmacist is often essential for this process. They can guide us on how we should discontinue or taper down a medication.

Let’s take a hypothetical case of classic polypharmacy problems:

A 82 years old lady comes in the emergency department on a Saturday night after a fall. She felt dizzy prior to the fall from her own height. Her exams is normal except for some bruising on her left arm, and orthostatic vitals 120/70 HR 52 lying down, 90/50 HR 87 standing. The work up is unremarkable, not problems at home. You are now ready to do a “brown bag biopsy”.

Let’s take one pill at the time. For the following statements, Sabrina Haq, the pharmacist I talked to you about earlier.

  • ASA 81mg PO od: indication reviewed; history of angina in the past, risks could be discussed with the patients.
  • Metropolol 50mg PO bid: started a long time ago for angina, HR at rest is 52, lowering the dose would be a good idea.
  • A statin: ask her family doctor to do a cholesterol study and decide if still indicated.
  • Ramipril 10mg PO od: monitor the blood pressure and consider lowering the dose.
  • Amlodipine 10mg PO od: monitor the blood pressure and consider lowering the dose
  • Zopiclone 5mg HS: definitely, increases the risk of car accident and falls, it should be discontinued eventually.
  • Ativan 1mg PO bid: The indication needs to be reevaluated by the family doctor because benzos are considered inappropriate for elderly but sometimes they get re-prescribed over time. Benzos need to be tapered down very slowly.
  • Trazodone 25mg PO HS: This medication increases the risk of orthostatism and falls. If only for sleep, try better sleep hygiene first, melatonin could be a good idea to try.
  • Citalopram 30mg PO od: re-evaluate the indication, after one-two year, we should try to discontinue it. If still indicated, lower the dose to a maximum of 20mg once daily (unless the dose was increased for a reason).
  • Cal + vit D: Evaluate the diet intake of calcium, if above 1200mg (approximately more than 2 glasses of milk and 1 yogurt), d/c because it can causes constipation as well. Vit D, the recommendation is 1000 ui once daily.
  • Vit B12: do a blood test of vit B12, if above 300,d/c
  • Sulfate ferrous 300mg PO od: again, review the Hb, if normal, d/c.
  • Docusate de sodium 200mg PO HS: D/C, no evidence about efficacy for constipation (I will talk about constipation someday)

**Remember that this cannot be all done at the emergency department. Especially for benzos who need to be tapered down sloooowly. Making multiple changes simultaneously may not be beneficial for the patient either. And remember to discuss the change you want to make with the patient. He might know better.

My final advice, as a doctor you should always question the medication. It is not because it is an old prescription that it is a good one now. You can use any tool you want but the best tools are your clinical judgment and the help from a pharmacist.

In conclusion, this may be the most important one, make sure that all the work you did will follow the patient to her pharmacy and her family physician. Write a note, an email, a fax, a pigeon! Communication!

References

  1. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert opinion on drug safety. 2014 Jan;13(1):57-65. PubMed PMID: 24073682. Pubmed Central PMCID: 3864987.
  2. Frank C, Weir E. Deprescribing for older patients. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2014 Dec 9;186(18):1369-76. PubMed PMID: 25183716. Pubmed Central PMCID: 4259770.
  3. Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. The Cochrane database of systematic reviews. 2012 (5):CD008165. PubMed PMID: 22592727.

 

 

2 thoughts on “Deprescribing

  1. Pingback: An approach to FALLS – Geriatric Emergency Medicine

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s