Deprescribing Flashcards
T/F: All medications on the Beer’s list should be discontinued at age 65
FALSE
Just use as a “warning light” for clinical decision-making
What is clinical inertia?
Keeping a patient’s therapy consistent when it is working instead of making changes for optimization that may not be necessary
What classes of drugs are potentially inappropriate medications for older adults (PIMs)?
- Anticholinergics
- Benzodiazepines
- Antidepressants
- NSAIDs
What are anticholinergic side effects?
- Impaired vision (falls/accidents)
- Dry mouth (infection/malnutrition)
- GI problems (malnutrition/pain)
- CV problems (anxiety/disease worsening)
- Urinary issues (incontinence/infection)
- CNS problems (dysfunction/impaired ADL)
What classes of drugs are anticholinergic?
- Muscle relaxants
- Antispasmodics
- TCAs
- Antihistamines
What is the anticholinergic activity level of amitriptyline?
25mg/17.6
What is the anticholinergic activity level of paroxetine?
20mg/5.4
What is the anticholinergic activity level of atropine?
0.4mg/20.25
What is the anticholinergic activity level of oxybutinin?
10mg/5.5
What is the anticholinergic activity level of tolterodine?
2mg/9.75
What indications make benzodiazepines appropriate for older adults?
- Seizures
- REM sleep behaviors
- Benzodiazepine withdrawal
- Ethanol withdrawal
- Severe anxiety
- Anesthesia for procedure
What is associated with a dose of >3mg of diazepam equivalents in older adults?
> 50% increase in hip fracture risk
T/F: SSRIs should be used instead of benzos for anxiety since they do not carry the same fall risk
FALSE: data shows us a similar increase in fall risk
What are some NSAID toxicities in older adults?
- GI effects (ulcers, PUD)
- CV disease
- Renal issues
NSAID GI toxicity is dose (dependent/independent)
Dependent
What can we use to prevent NSAID GI toxicity?
- Misoprostol (needs high dose)
- H2RA (doubled dose needed)
- PPIs (gold standard)
COX-2 selective agents should be used for high-risk patients
T/F: All NSAIDs increase risk of acute MI, INCLUDING celecoxib and naproxen
TRUE
When should you especially avoid NSAIDs in older adults?
History of MI/stroke
What do NSAIDs do to the kidneys?
- Reduction in renal blood flow
- Sodium/water retention
(Fluid overload, acute renal failure)
What are the domains of of deprescribing barriers?
- Individual/patient factors
- Sociocultural factors
- Personal and relational factors
- Organizational factors
What are the steps of deprescribing?
- Comprehensive med history
- Identify inappropriate meds
- Determine if it/they can be deprescribed
- Plan and initiate deprescribing
- Monitor, support, document
What would make a med discontinuable?
- No valid indication
- Part of a prescribing cascade
- Harm clearly outweighs potential benefit
- Preventative med unlikely to confer benefit (older patients)
- Impose unacceptable treatment burden
Patient wishes + Clinician opinion = ?
Shared healthcare decisions
What are drug-related risk factors of drug induced harm?
- Number of medications prescribed
- Use of potentially inappropriate or “high risk” drugs
- Past or current toxicity
What are patient-specific risk factors of drug induced harm?
- Age >80 years
- Cognitive impairment
- Multiple comorbidities
- Multiple prescribers
How should you prioritize medications to be deprescribed?
- Most harm and least benefit
- Easiest to stop
- Those that the patient is willing to stop first (can lead to further deprescribing)
What is the time to benefit (TTB)?
Time it takes for medication effects to become evident in a population
What is the time to harm (TTH)?
Time until a significantly significant adverse effect is seen in a trial for the treatment group compared to control
What is the TTB estimated for bisphosphonates?
8-19 months
What is the TTB estimated for primary prevention statins?
2-5 years
What is the TTB estimated for primary prevention antihypertensives?
1-2 years
What is the TTB estimated for primary prevention aspirin?
10 years
What is the TTB estimated for intensive glucose control in diabetes?
10 years
What are some general rules for deprescribing?
- Make sure patient is on-board
- Discontinue one drug at a time
- Taper when withdrawal is a concern
- Communicate with caregivers and doctors