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
Risks with digoxin
More susceptible to digoxin toxicity as renal cleared
Anticholinergic drugs
Isosorbide dinitrate
Furosemide
Theophylline
Nifedipine
Drugs that increase ER visits
Antiinfective agents
Anticoagulants
Antineoplastic agents
Opioids
10 classes of drugs with underprescribing
· ACE inhibitors for patients with diabetes and proteinuria
· Angiotensin-receptor blockers
· Anticoagulants- for stroke prevention in a-fib
· Antihypertensives and diuretics- uncontrolled hypertension
· β-blockers- after myocardial infarction or with heart failure
· Bronchodilators- COPD
· Proton-pump inhibitors or misoprostol- GI protection from NSAIDs
· Statins- secondary prevention
· Vitamin D and calcium- patients with or at risk of osteoporosis
· Bisphosphonates- fracture prevention
Risks of venlafaxine
Nausea/GI upset
Insomnia/Anxiety
Tachycardia/Palpitations
HTN
Risks of mirtazapine
Weight gain
Hypersomnolence
Dry mouth
Risks of diltiazem
Peripheral edema
Risks of tiotropium
Anticholinergic - dry mouth, hoarse/laryngitis
Risks of budesonide
Candida, hoarseness
Risks of calcium
Constipation
What are two evidence based resources to support medication review and deprescribing in older adults?
- Beers Criteria
- STOPP/START
- Choosing Wisely
- Anticholinergic risk scale
Elderly female family worried patient missing doses. Give 5 suggestions to prevent her from missing doses.
- Leave medications in plain view
- Pill containers: that have compartments for days or time of day
- Blister pack
- Calendar: mark down time/day you took medication
- Alarms
