Deprescribing: A simple method for reducing polypharmacy

,; ,; ,; ,; ,

Applied Evidence

Deprescribing: A simple method for reducing polypharmacy

J Fam Pract. 2017 July;66(7):436-445

PDF Download

From The Journal of Family Practice | 2017;66(7):436-445.

References

1. Bourgeois FT, Shannon MW, Valim C, et al. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiol Drug Saf. 2010;19:901-910.

2. Nair NP, Chalmers L, Peterson GM, et al. Hospitalization in older patients due to adverse drug reactions–the need for a prediction tool. Clin Interv Aging. 2016;11:497-506.

3. Nguyen JK, Fouts MM, Kotabe SE, et al. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother. 2006; 4:36-41.

4. Hohl CM, Dankoff J, Colacone A, et al. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 2001;38:666-671.

5. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246.

6. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213-218.

7. Shah BM, Hajjar ER. Polypharmacy, adverse drug reactions, and geriatric syndromes. Clin Geriatr Med. 2012;28:173-186.

8. Magaziner J, Cadigan DA, Fedder DO, et al. Medication use and functional decline among community-dwelling older women. J Aging Health. 1989;1:470-484.

9. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13:57-65.

10. Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588-595.

11. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician. 1998;57:2675-2694.

12. Syed Q, Hendler KT, Koncilja K. The impact of aging and medical status on dysgeusia. Am J Med. 2016;129:753, E1-E6.

13. Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother. 2004;38:303-312.

14. Espino DV, Bazaldua OV, Palmer RF, et al. Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study. J Gerontol A Biol Sci Med Sci. 2006;61:170-175.

15. Akazawa M, Imai H, Igarashi A, et al. Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother. 2010; 8:146-160.

16. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54:1516-1523.

17. Qato DM, Wilder J, Schumm LP, et al. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176:473-482.

18. Flaherty JH, Perry HM 3rd, Lynchard GS, et al. Polypharmacy and hospitalization among older home care patients. J Gerontol A Biol Sci Med Sci. 2000;55:554-559.

19. Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53:1518-1523.

20. Gerteis J, Izrael D, Deitz D, et al. Multiple chronic conditions chartbook. Rockville, MD: Agency for Healthcare Research and Quality. 2014.

21. American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc. 2012;60:E1-E25.

22. Woodward M. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33:323-328.

23. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170:1648-1654.

24. Page AT, Clifford RM, Potter K, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis. Br J Clin Pharmacol. 2016;82:583-623.

25. Reeve E, Shakib S, Hendrix I, et al. The benefits and harms of deprescribing. Med J Aust. 2014;201:386-389.

26. Walsh K, Kwan D, Marr P, et al. Deprescribing in a family health team: a study of chronic proton pump inhibitor use. J Prim Health Care. 2016;8:164-171.

27. Orwig D, Brandt N, Gruber-Baldini AL. Medication management assessment for older adults in the community. Gerontologist. 2006;46:661-668.

28. Anderson K, Jue SG, Madaras-Kelly KJ. Identifying patients at risk for medication mismanagement: using cognitive screens to predict a patient’s accuracy in filling a pillbox. Consult Pharm. 2008;23:459-472.

29. Lenaerts E, De Knijf F, Schoenmakers B. Appropriate prescribing for older people: a new tool for the general practitioner. J Frailty & Aging. 2013;2:8-14.

30. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. IMAJ. 2007;9:430-434.

31. Holmes HM, Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA Intern Med. 2015;175:701-702.

32. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175:827-834.

33. Guirguis-Blake JM, Evans CV,Senger CA, et al. Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016;164:804-813.

34. Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;3:CD007726.

35. Petersen LK, Christensen K, Kragstrup J. Lipid-lowering treatment to the end? A review of observational studies and RCTs on cholesterol and mortality in 80+-year olds. Age Ageing. 2010;39:674-680.

36. Banach M, Serban MC. Discussion around statin discontinuation in older adults and patients with wasting diseases. J Cachexia Sarcopenia Muscle. 2016;7:396-399.

37. Goldstein MR, Mascitelli L, Pezzetta F. Statin therapy in the elderly: misconceptions. J Am Geriatr Soc. 2008;56:1365.

38. Han BH, Sutin D, Williamson JD, et al, for the ALLHAT Collaborative Research Group. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT Randomized Clinical Trial. JAMA Intern Med. Published online May 22, 2017.

39. Sever PS, Chang CL, Gupta AK, et al. The Anglo-Scandinavian Cardiac Outcomes Trial: 11-year mortality follow-up of the lipid-lowering arm in the U.K. Eur Heart J. 2011;32:2525-2532.

40. Denardo SJ, Gong Y, Nichols WW, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med. 2010;123:719-726.

41. Ekbom T, Lindholm LH, Oden A, et al. A 5‐year prospective, observational study of the withdrawal of antihypertensive treatment in elderly people. J Intern Med. 1994;235:581-588.

42. Iyer S, Naganathan V, McLachlan AJ, et al. Medication withdrawal trials in people aged 65 years and older. Drugs Aging. 2008;25:1021-1031.

43. Campbell AJ, Robertson MC, Gardner MM, et al. Psychotropic medication withdrawal and a home‐based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47:850-853.

44. Pollmann AS, Murphy AL, Bergman JC, et al. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review. BMC Pharmacol Toxicol. 2015;16:19.

45. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Can Fam Phys. 2017; 63:354-364.

46. Duncan P, Duerden M, Payne RA. Deprescribing: a primary care perspective. Eur J Hosp Pharm. 2017;24:37-42.

47. Schuling J, Gebben H, Veehof LJ, et al. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56.

48. Scott I, Anderson K, Freeman CR, et al. First do no harm: a real need to deprescribe in older patients. Med J Aust. 2014;201:390-392.

CASE During the office visit, you advise the patient that her BP looks normal, her blood sugar is within an appropriate range, and she is lucky to have not sustained any injuries after her most recent fall. In addition to discussing the benefits of some outpatient physical therapy to help with her balance, you ask if she would like to discuss reducing her medications. She is agreeable and asks for your recommendations.

You are aware of several resources that can help you with your recommendations, among them the STOPP/START⁶ and Beers criteria,⁵ as well as the Good Geriatric-Palliative Algorithm.³⁰

If you were to use the STOPP/START and Beers criteria, you might consider stopping:

lorazepam, which increases the risk of falls and confusion.
ibuprofen, since this patient has only mild osteoarthritis pain, and ibuprofen has the potential for renal, cardiac, and gastrointestinal toxicities.
oxybutynin, because it could be contributing to the patient’s constipation and cause confusion and falls.
furosemide, since the patient has no clinical heart failure.
omeprazole, since the indication is unknown and the patient has no history of ulceration, esophagitis, or symptomatic gastroesophageal reflux disease.

After reviewing the Good Geriatric-Palliative Algorithm,³⁰ you might consider stopping:

clopidogrel, as there is no clear indication for this medication in combination with aspirin in this patient.
glipizide XL, as this patient’s A1c is below goal and this medication puts her at risk of hypoglycemia and its associated morbidities.
metformin, as it increases her risk of lactic acidosis because her GFR is <45 units.
docusate, as the evidence to show clear benefit in improving chronic constipation in older adults is lacking.

There have been no reported adverse drug withdrawal events or deaths associated with deprescribing.

You tell your patient that there are multiple medications to consider stopping. In order to monitor any symptoms of withdrawal or return of a condition, it would be best to stop one at a time and follow-up closely. Since she has done well for the past week without the glipizide and lisinopril-HCTZ combination, she can remain off the glipizide and the HCTZ. Lisinopril, however, may provide renal protection in the setting of diabetes and will be continued at this time.

You ask her about adverse effects from her other medications. She indicates that the furosemide makes her run to the bathroom all the time, so she would like to try stopping it. You agree and make a plan for her to monitor her weight, watch for edema, and return in 4 weeks for a follow-up visit.

On follow-up, she is feeling well, has no edema on exam, and is happy to report her urinary incontinence has resolved. You therefore suggest her next deprescribing trial be discontinuation of her oxybutynin. She thanks you for your recommendations about her medications and heads off to her physical therapy appointment.

CORRESPONDENCE
Kathryn McGrath, MD, Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University, 2422 S Broad St, 2nd Floor, Philadelphia, PA 19145; Kathryn.mcgrath@jefferson.edu.