Deprescribing Eng Version

8/3/2019 Deprescribing Eng Version

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enrique gavilángeneral practitioner

researchdepartment

polypharmacylaboratory

VI jornadasuso adecuadomedicamentos

Plasencia3 nov 2011

www.polimedicado.com / [email protected]



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what is “deprescribing”?

how to deprescribe?

what´re the basis?

how to desprescribe? who? by whom?

does it works?

what´re the risk / barriers / threats?



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discontinuation

drug removal / cessation

drugectomy

from polypharmacy to

oligopharmacy



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cut off

pruning logging



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extirpation



+ gotic deco

minimalism



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therapeutic retirement

How? Fernandez did not

come to work becausehe´s been buried? Well, Ihope he do not forget tobring a certificate!



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deprescribing

following up

supplying

prescribing

indicating

diagnosing

therapeutic chain



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deprescribingprescribing



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process of adaptation of drugregimen: tappering, replacing,eliminating drugs

must take in consideration thescientific evidence, social and physicalfunction, comorbidity, quality of life and

patient´s preferences



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1. review, review and again review

2. reconsider therapeutic plan

3. taper off, eliminate, substitute

4. agree with the patient / caregiver

5. follow up

Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51. Bain KT, et al. JAGS.2008;56:1946-52. Woodward MC. J Pharm Pract Research. 2003;33:323-8.



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review complete list of drugs

be careful with over the counter drugs,naturopathics, non solid drugs

medication reconciliation in medicaltransitions

poor congruence with patient (58%)

Bikosky RM et al. JAGS. 2001;49:1353-7



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Holmes H, et al. Arch Intern Med. 2006;166:605-9



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Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51

review the indication (active?, goals?,time to benefit?)

analize the compliance degree

detect adverse effects (present and risk)

detect drug-drug and drug-disease

interactions



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no longer used drugs

drugs for inactive or cured diseases

those that caused adverse effects

those that pottentially would causerelevant harms

vicious drug waterfalls

Woodward MC. J Pharm Pract Research. 2003;33:323-8



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Beers criteria

Examples:

- digoxin, 0,25 mg/d, in heart failure

- amitriptiline –anticholinergic andsedative properties-

- long life benzodiazepines –fall risk andsedation-

Fick DM, et al. Arch Intern Med. 2003;163:2716-24



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STOPP-START criteria

Examples:

- thiazides if history of gout

- NSAID if uncontrolled HBP, renalfailure or gastric bleeding

- bladder antimuscarinics if history of dementia or glaucoma

Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46:72-83



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Maddison AR, et al. Prog Palliat Care. 2011;19:15-21



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explaining and involving

talking, informing, and, above all,listening

preferences, expectations, beliefs

adapt rythm to real posibilities



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enhancing therapeutic adherence

highlighting achievements

supporting

detecting recurrence or worseningsymptoms



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inappropriate polypharmacy as a publichealth problem

absence of scientific evidence for certaindrugs

ethics criteria

patient´s preferences



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Wilcox SM, et al. JAMA. 1994;272:292-6. Rollason V, Vot N. Drugs Aging.2003;20:817-32

40% of institutionalized & 25% of outpatientelderly has at least one inappropriate drug

20% >70 years use 5 or more drugs difficult adherence, adverse effects,

interactions, falls, morbidity, hospitaladmissions…



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Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31



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N = 339. Age > 80 yJyrkkä et al. Drugs Aging. 2009; 26:1039-48



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are thereelderly in

clinicalstudies?

what tellsthe

studies?and the

guidelines?

are thereevidences?



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Lee PY, et al. JAMA. 2001;286:708-13



60-64 65-69 70-74 75-79 80-84 85-89 90-94

10

20

30

%

patients included in clinical trials

general population with dementia

age (years)Schoenmaker N, Van Gool WA. Lancet Neurol. 2004;3:627-30



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RR = 0.82 (0.69-0.99)NNT = 46 (637- 24)

HYVET Study. Beckett NS, et al. NEJM. 2008;358:1887-98



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Carey EC, et al. JAGS. 2008; 56:68–75

• dependence personalhygiene: 1 point• dependence indressing: 1-3 points• malignant disease: 2points• congestive heartfailure: 3 points• COPD: 1 point• renal failure: 3 points



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• congestive heart failure requiring treatment witha diuretic or ACO inhibitors• renal failure (serum creatinine > 150 µmol/l)

• condition expected to severely limit survival,e.g. terminal illness

• clinical diagnosis of dementia• resident in a nursing home (dependence)• unable to stand up or walk…

clinicaltrials.gov/



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Van Bemmel T, et al. J Hypertens. 2006;24:287-92



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Iyer S, et al. Drugs Aging. 2008;25:1021-31



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Walma EP, et al. BMJ 1997;315:464–8



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Shepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7

N = 5804, 70-82 y



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The fallacy of cheating death hasbeen promulgated by the apostles of

altered life-stile. In their enthusiasm,

they have failed to stress that

escaping death from myocardial

infarction allows the possibility of

dying from cancer, stroke or

Alzheimer Disease

Mc Cormick JS, Skrabanek P. Lancet. 1984;2:1455-6



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Hello, guy! How well you've come!



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Emslie C, et al. Coronary Health Care. 2001;5:25-32Mangin D, et al. BMJ. 2007;335:285-7

if it occurs in young patients: fast death,without suffering

in the elderly: a natural dying, “a good wayof dying"



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• ibandronate, etidronateno studies in this age group

alendronate

only one trial that includes >80 y women: RRR non vertebral fractures46% (not as end point) (Pols 1999)

• risedronate- secondary prevention: RRR in morphologic vertebral fractures81%, no effect on non-vertebral (Boonen 2004)- low risk primary prevent.: no effect hip fracture (McClung 2001)

• zoledronate- secondary prevention, 55% >75 y: RRR any new fracture 5%, noeffect on hip fracture (Lyles 2007)

- primary prevention, 37% > 75 y: RRR morphologic vertebralfractures 70%, 41% on hip fracture (Black 2007)

Inderjeeth CA. Bone. 2009;44:744-51. Parikh S. J Am Geriatr Soc. 2009;57:327–34.Chua WM. Ther Adv Chonic Dis. 20011;2:279-86



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McClung MR, et al. NEJM 2001;344:333–40

RR = 0.6 (0.4–0.9), p = 0.009 RR = 0.8 (0.6–1.2), p = 0.35



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application of NOF guidelines to general population

estimated that at least 34% of US white men aged

65 years and older and 49% of those aged 75

years and older would be recommended for drug treatment

Donaldson MG, et al. J Bone Mineral Res. 2010;25:1506–11



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Black DM, et al. JAMA. 2006;296:2927-38



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Lai SW, et al. Medicine.2010;89:295-99



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Boyd CM, et al. JAMA. 2005; 294:716-24

disease

Information

about elderlypatients?

Information

about multiplecomorbidity?

Information

about elderlywith multiple

comorbidity?

diabetes mellitus Yes Yes Yes

hypertension Yes No Noosteoartrhitis Yes Yes Yes

osteoporosis No No No

COPD No No No

atrial fibrilation Yes Yes Yes

congestive heart failure Yes Yes Noangina Yes Yes Yes

hypercholesterolemia Yes Yes No



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hypothetic patient. 79 years, hypertension, COPD, type 2diabetes, osteoporosis and osteoarthritis (all moderate)

Boyd CM, et al. JAMA. 2005; 294:716-24



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Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52



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terminal patients: symptoms and personal care(no pain, no anxiety, no dyspnea, personalhygiene), preparation for death, stay mentally alert

elderly: willingness to take preventive medicationsis very unsensitive to benefits but high sensitive toadverse effects

reducing drugs do not solve all problems and

concerns of the elderly ...

Steinhauser KE. JAMA. 2000; 284:2476-82. Fried TR. Arch Intern Med. 2011;171(10):923-8.Moen J. Patient Educ Couns. 2009;74:135-41



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poda

given a particular patient, reconsider the therapeutic regimen, deprescribingthe unnecessary drugs

moreindividualizing

timeconsuming



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do the benefits outweigh the risks?

exceeds the life expectancy of this

patient the drug time to benefit? is it a logical piece in the current

treatment regimen? Compare theindications for the drug and the goalsof this patient care



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Garfinkel D, Mangin D. ArchIntern Med.

2010;170:1648-54



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tala

given a particular inappropriate drug,review every patient that uses it and act

morefeasible

less flexible



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outside agent: greater objetivity,worse actual knowledge about patient´senvironment

bedside health proffesional: greater acceptance (trust, longitudinal attention,accessibility)

Moen J. Patient Educ Couns. 2009;74:135-41



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drugs reduction (mean 0.5-2.8/patient)

hospital referals, less than control group (12% Vs 30%)

mortality, less than control group (21% Vs 45%)

no effect on quality of life and mental status

no relevant adverse effects

lower costs: 0,46 $ person/day

limitations: small trials, no good randomization, noblind evaluation, selection bias…

Garfinkel D, et al. Isr Med Assoc J. 2007;9:430-4. Garfinkel D, Mangin D. Arch InternMed. 2010;170:1648-54. Beer C, et al. Ther Adv Drug Safe. 2011;2:37-43



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Hardy JE, Hilmer SH. J Pharm Pract Res. 2011;41:146-51



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In the end I didn't know what was worse,

um, having the … withdrawal effects from it

or having the, um … depression side of it

I don't think I take them to sustain my

mood but purely just to stop the side

effects. I'll maybe be just have to grin and

bear it

Leydon GM, et al. Fam Pract. 2007;24:570-5



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tapper or discontinue gradually

better in those with few drugs for aspecific process

close follow up at the beggining

“opened door”

shared decisions

flexibility: any change is irreversibleLeydon GM. Fam Pract. 2007;24:570-5



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health system

e-prescribing

aggresive guidelines

induced prescribing

physician barriers

prescribing, associated to every clinical encounter

overmedicalization and overtherapeutic inertia we are not programmed to desprescribing

lack of skills to change patient´s attitudes



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physician-patient relationship

not addressing deprescribing with patient / family

not considering patient´s perpective

patient

“the time is over” / feeling of surrender

fears, unpleasant past experiences

Leydon GM. Fam Pract. 2007;24:570-5. Hardy JE. J Pharm Pract Res. 2011;41:146-51



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ageism

paternalism or assymetry in decisionmaking (i decide, then i inform you )

forgetting the non-pharmacologicalaspects (psychological, social andfamily context, health systemperformance, expectations, clinicalrelationship ...)

Barsky AJ. Arch Intern Med. 1983;143:1544-8

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firstly, non-pharmacological approach

seeking the causes of the causes (fundamentalcauses)

wait and see

a few drugs, but well used

the newest is not always the best

changes, one by one adverse effects, on the jagged edge

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anticipate possible adverse effects

unbiased sources of information and learning

enhance adherence

patient-centered clinical outcomes rather thansurrogate or intermediate markers

remove the needless drugs

promote conservative desires and healthyskepticism in patientsSchiff GD, et al. Principles of conservative prescribing. Arch Inter Med. 2011



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It is an art of no little importance to

administer medicines properly: but, it is an

art of much greater and more difficult

acquisition to know when to suspend or altogether to omit them

Philippe Pinel. A treatise on insanity.1806

Antonio Villafaina

Rafa Bravo

Sergio Minué

Beatriz González

Marc Jamoulle

and all of you

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