Polypharmacy

Deprescribing in Polypharmacy

7 minutes

Managing patients individually and holistically can mitigate the risk of overprescribing

Deprescribing may be defined as the process of reducing or discontinuing medicines that are unnecessary or deemed harmful.1 In that sense, deprescribing is the antidote for polypharmacy. There are numerous health benefits of deprescribing, including reduced side effects, improved cognition, reduction in falls, better medication adherence, and improvement in quality of life.1 These effects are especially prominent in the geriatric population, as the dynamic health needs of this population may not be addressed in a timely fashion.2,3

Deprescribing practices

Patients undergoing the process of deprescribing should be closely monitored to ensure any signs of complication or disease exacerbation are detected.4 An interesting finding noted that clinical education curricula integrated into undergraduate, graduate and continuing medical education could lay the foundation of this culture shift towards deprescribing.5

Electronic health records should be utilized to leverage polypharmacy practices and provide decision support with prescribing advice rendered in real time with multiple provider interoperability for optimal coordination of care.5

As nurse practitioners, we know how important it is to evaluate each patient’s prescription plan. Being a central player to our patient’s care is key to managing chronic conditions treatment specifically. Recent evidence suggests that the best way we can manage a patient’s care is through reviewing medications and the duration of treatment plans.6,7

A relevant example of deprescribing in chronic conditions is evident with proton pump inhibitors (PPI), as they can often be discontinued when no longer necessary.8

A large retrospective review done on polypharmacy practices from the last decade reported that reducing the dose or, in appropriate cases, discontinuing oral hypoglycemics medications in elderly patients, seemed to be feasible while still maintaining acceptable glycemic control.9 Another study concluded that for the patients whose treatment resulted in very low levels of HbA1c or blood pressure (BP), only up to 27% underwent deintensification, suggesting that deprescription (or in this case dose-lowering) practice could cover a larger subset of patients without affecting BP or glucose levels.10 Practice guidelines and performance measures are critically lacking in this area. Black, et al. did a literature review and found that only two controlled studies were performed on deprescribing in diabetics – one of which showed that educating stakeholders decreased glyburide without worsening glucose control, and the other reported that discontinuing antihyperglycemics in elderly nursing home patients did not significantly increase HbA1C.11,12

Some of the key barriers to deprescribing include inadequate guidelines incomplete medical histories and lack of time 13 There has been a push for adopting an individualized approach to address polypharmacy in elderly patients.14 Ultimately, an individualized approach to patient care is essential in the nurse practitioner practice, specifically as patients’ needs may change with age.15. This type of screening provides an avenue for the discussion of each medication’s appropriateness, and allows the patient to be informed on the correlation of health goals with medication regimen.16,17

Ultimately, the process of deprescribing recognizes that patients’ needs are key in any medication regimen, and that these needs are dynamic based on appropriate goals of chronic disease outcome indicators.18 Integrating a stepwise approach to polypharmacy and potential deprescribing needs allows for cost effectiveness in multimorbidity management, providing economic implications for patients19. Cost effectiveness of treatment plans can be easily overlooked, and often confound management of polypharmacy in multi-morbidities.20

Following a comprehensive, individualized approach in collaboration with other clinicians can mitigate the risk of overprescribing and facilitate treatments individualized to the patient, not treatments targeted to guidelines that may not apply to your patient.21 The most important point in medication management is to remember that the specific patient goals must continually be accounted for in polypharmacy regimens.22 Critical indicator outcome goals (i.e., A1C, LDL, etc.) in chronic disease can be determined for each individual patient and monitored thusly.23 A continuity of care plan based on a primary healthcare provider’s input into medication management should integrate principles of deprescribing.24,25

Table 1 provides our suggested step-wise process for deprescribing.

Action  Description
1. Interview Interview each patient (and/or their caregivers when necessary) in full detail, focusing on current, coexisting and past diseases, their management, including a full medication history.
2. Medication Reconciliation Perform comprehensive medication reconciliation to check for current and previous prescriptions, checking for adverse effects, drug-disease and drug-drug interactions. Also check for correct dosage.
3. Examination Examine the patient with a focus on possible side effects of the prescribed medications that may be otherwise overlooked.
4. Deprescription Based on all the above, determine which medications are redundant, unnecessary, having deleterious effects and could be discontinued or replaced.
5. Follow-up Schedule frequent follow-ups with the patients (including getting lab work where necessary) to ensure that there are no withdrawal symptoms, worsening of existing conditions or development of new health issues based on the deprescription performed.
6. Collaboration Work together with other clinicians and pharmacist to ensure accuracy of medication regimen plan.
7. Documentation  Document everything in an electronic health record for continuity of care and treatment plan.

Table 1: Suggested stepwise protocol for proper deprescribing.

Conclusion

Managing patients individually and holistically, rather than treating towards a guideline, can lead to promote deprescribing practices in polypharmacy management. Through implementation of the stepwise approach suggested, polypharmacy can be effectively and dynamically managed, one patient a time.

 

 

 

 

 

 

References

  1. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. Challenges and Enablers of Deprescribing: A General Practitioner Perspective. Cox D, ed. PLoS One. 2016;11(4):e0151066. doi:10.1371/journal.pone.0151066.
  2. Fulton MM, Riley Allen E. Polypharmacy in the elderly: A literature review. J Am Acad Nurse Pract. 2005;17(4):123-132. doi:10.1111/j.1041-2972.2005.0020.x.
  3. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230. doi:10.1186/s12877-017-0621-2.
  4. Dills H, Shah K, Messinger-Rapport B, Bradford K, Syed Q. Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials. J Am Med Dir Assoc. 2018;19(11):923-935.e2. doi:10.1016/J.JAMDA.2018.06.021.
  5. Mishori R. What Needs to Change to Make Deprescribing Doable. Fam Pract Manag. 2018;25(3):5-6. https://www.aafp.org/fpm/2018/0500/p5.html. Accessed November 8, 2018.
  6. Moriarty F, Pottie K, Dolovich L, McCarthy L, Rojas-Fernandez C, Farrell B. Deprescribing recommendations: An essential consideration for clinical guideline developers. Res Soc Adm Pharm. September 2018. doi:10.1016/J.SAPHARM.2018.08.014.
  7. McCarthy D. Institute for Healthcare Improvement: Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement. hhttp://www.ihi.org/resources/Pages/Publications/Evidence-Based-Medication-Deprescribing-Innovation-Case-Study.aspx. Published 2017. Accessed November 8, 2018.
  8. Andreassen LM, Kjome RLS, Sølvik UØ, Houghton J, Desborough JA. The potential for deprescribing in care home residents with Type 2 diabetes. Int J Clin Pharm. 2016;38(4):977-984. doi:10.1007/s11096-016-0323-4.
  9. Abdelhafiz AH, Sinclair AJ. Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications. 2018;32(4):444-450. doi:10.1016/J.JDIACOMP.2017.11.011.
  10. Sussman JB, Kerr EA, Saini SD, et al. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med. 2015;175(12):1942. doi:10.1001/jamainternmed.2015.5110.
  11. Black CD, Thompson W, Welch V, et al. Lack of Evidence to Guide Deprescribing of Antihyperglycemics: A Systematic Review. Diabetes Ther. 2017;8(1):23-31. doi:10.1007/s13300-016-0220-9.
  12. Bemben NM. Deprescribing: An Application to Medication Management in Older Adults. Pharmacother J Hum Pharmacol Drug Ther. 2016;36(7):774-780. doi:10.1002/phar.1776.
  13. Reeve E, Simon Bell J, N. Hilmer S. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. Curr Clin Pharmacol. 2015;10(3):168-177. https://www.ingentaconnect.com/content/ben/ccp/2015/00000010/00000003/art00003. Accessed November 8, 2018.
  14. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 2016;91:115-134. doi:10.1016/j.maturitas.2016.06.006.
  15. Rankin A, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;9:CD008165. doi:10.1002/14651858.CD008165.pub4.
  16. Kim LD, Koncilja K, Nielsen C. Medication management in older adults. Cleve Clin J Med. 2018;85(2):129-135. doi:10.3949/ccjm.85a.16109.
  17. Zullo AR, Gray SL, Holmes HM, Marcum ZA. Screening for Medication Appropriateness in Older Adults. Clin Geriatr Med. 2018;34(1):39-54. doi:10.1016/j.cger.2017.09.003.
  18. Swinglehurst D, Fudge N. The polypharmacy challenge: time for a new script? Br J Gen Pract. 2017;67(662):388-389. doi:10.3399/bjgp17X692189.
  19. Kim J, Parish AL. Polypharmacy and Medication Management in Older Adults. Nurs Clin North Am. 2017;52(3):457-468. doi:10.1016/j.cnur.2017.04.007.
  20. Lin H-W, Lin C-H, Chang C-K, et al. Economic outcomes of pharmacist-physician medication therapy management for polypharmacy elderly: A prospective, randomized, controlled trial. J Formos Med Assoc. 2018;117(3):235-243. doi:10.1016/J.JFMA.2017.04.017.
  21. Bain KT, Knowlton CH, Turgeon J. Medication Risk Mitigation: Coordinating and Collaborating with Health Care Systems, Universities, and Researchers to Facilitate the Design and Execution of Practice-Based Research. Clin Geriatr Med. 2017;33(2):257-281. doi:10.1016/j.cger.2017.01.009.
  22. Hernandez J. Medication management in the older adult. J Am Assoc Nurse Pract. 2017;29(4):186-194. doi:10.1002/2327-6924.12427.
  23. Beuscart J-B, Pont LG, Thevelin S, et al. A systematic review of the outcomes reported in trials of medication review in older patients: the need for a core outcome set. Br J Clin Pharmacol. 2017;83(5):942-952. doi:10.1111/bcp.13197.
  24. Köberlein-Neu J, Mennemann H, Hamacher S, et al. Interprofessional Medication Management in Patients With Multiple Morbidities. Dtsch Arztebl Int. 2016;113(44):741-748. doi:10.3238/arztebl.2016.0741.
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Editor’s note: this post was originally published on February 19, 2019.

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