Deprescribing Flashcards
Medications that can cause LUTS (3)
- Donepezil (worsen UI)
- Hydromorphone (constipation, urinary retention)
- Empagliflozin (SGLT-2i)
5 reasons to discontinue cholinesterase inhibitors (CCCDTD-5)
- Worsening dementia over last 6 months
- No benefit observed at any time
- Severe/End stage dementia
- Intolerable side effects
- Difficulties with medication compliance
What is a prescribing cascade?
A pattern of prescribing where a side effect from one medication is interpreted as a new medical condition and causes prescribing of a new medication
Examples:
1. Iron supp –> constipation –> Senna
2. Diltiazem –> peripheral edema –> Lasix
3. Venlafaxine –> inc alertness –> melatonin
4. Salbutamol –> inc HR –> bisoprolol
5 steps in a deprescribing protocol
- Determine all drugs being taken and reasons
- Consider overall risk of drug induced harm to determine intensity of deprescribing
- Assess each drug for current/future benefit and compare with harm/burden
- Prioritize drugs for discontinuation (lowest benefit-harm ratio, least likely to have withdrawal/rebound)
- Implement discontinuation regimen and monitor for AE/outcomes
Six adverse outcomes with benzos
- Psychomotor retardation
- Falls/fractures
- Impaired memory
- Increased mortality
- Increased traffic accidents
- Respiratory outcomes with COPD
Septra is a ____ inhibitor. Can alter metabolism of ____ (6).
CYP2C9
1. Glyburide/metformin/sulfonylureas = hypoglycemia
2. Warfarin = inc INR
3. Phenytoin = toxicity
4. Methotrexate = toxicity
5. ACE/ARB = hyperk
6. Alcohol
8 appropriate prescribing rules for older adults
- Start low, go slow, one at a time
- Consider current meds, comorbidities, goals, values, life expectancy/time to benefit
- Simplify regimen timing
- Involve patient, educate and assess understanding/compliance
- Consider drug-drug interactions, adjust for kinetics/dynamics
- Discontinue drugs when no longer needed, reassess regularly
- Avoid higher risk meds
- Consider alternative non-pharm therapies
Reason to stop HCTZ
Orthostatic HOTN
Falls
Reason to stop glyburide
Sulfonylurea - inc risk hypoglycemias
Reason to stop ASA
Not for primary prevention
Reason to stop pregabalin
Sedation
Falls
Reason to stop PPI
After 8 weeks of use unless high risk patient
Risks: GI cancer, PNA, C diff infection, falls/fracture, impaired iron absorption
Reason to stop BB
Falls
Orthostatic hOTN
Not first line for hTN in older adults
9 barriers to physician deprescribing
- Clinical complexity
- Limited consultation time
- Fragmented care w/ multiple providers
- Incomplete information on rationale for previously prescribed drugs
- Ambiguous or changing care goals
- Uncertain about benefits and harms of stopping
- Community/professional attitudes towards more rather than less
- Fear of withdrawal side effects
- Pressure to prescribe from disease specific guidelines
CrCl cut offs for bisphosphonates
Alendronate <= 35 mL/min
Zolendronic acid <=35 mL/min
Risedronate <= 30 mL/min
