Deprescribing Flashcards
consequences of polypharmacy
ADE, drug-drug interactions, cognitive impairment, functional decline, non-adherence, ↑ cost, falls
barriers to deprescribing
individual/patient factors, sociocultural factors, personal and relational factors, organizational factors
sociocultural barriers
medical culture of prescribing
relational barriers
uncertainty, fear/accountability, professional relationships
individual barriers
patient uncertainty, “doctor knows best”, impaired cognition
organizational barriers
limited time, no targeted funding, care fragmentation
process of deprescribing
comprehensive med history → identifying PIM → prioritize deprescribing → initiate withdrawal → monitor, support, document
comprehensive med history
ask about all prescribed, OTC, supplements and assess adherence and the reasons why they’re not being taken
meds that would be good for d/c
no valid indication, part of prescribing cascade, harm clearly outweigh benefit (PIM), preventative meds unlikely to provide benefit, drugs imposing treatment burden
tools to deprescribing
beers criteria, STOPP/START criteria, medication appropriateness index, VIONE, deprescribing.org
potential drug induced harm drug factors
number of medications prescribed, use of PIM or “high-risk” meds, past or current toxicity
potential drug induced harm patient factors
age >80 yo, cognitive impairment, multiple comorbidities, multiple prescribers
prioritize (what to stop first)
those with likelihood of greatest harm and least benefit, those easiest to d/c (no withdrawal or rebound), those that the patient is most willing to d/c (gain buy-in)
estimating risk of harm and benefit
number needed to treat, measures on benefit over a defined period of time, inversely related to life expectancy
ex: if NNT for drug x to prevent an MI is 20 at 5 years, the NNT would be much higher to prevent MI over 1 year
time to benefit
the time it takes for a medications effect to become evident
time to harm
the time until a significant adverse effect is seen in a trial for the treatment group competed to the control group
TTB vs TTH example
intensive glucose control in DM
TTB: 10 years
TTH: minutes
estimated TTB for selected meds
bisphosphonates for OP: 8-19 mo
statins 1* prevention: 2-5 years
HTN 1* prevention: 1-2 years
aspirin 1* prevention: 10 years
Intensive glycemic control in DM: 10 years
if life expectancy < TTB
med not recommended, consider d/c, may contribute risk without possible benefit
if life expectancy = TTB
defer to patients values and preferences, shared decision making
if life expectancy > TTB
med may have benefit and can be continued, consider relationship of TTB and TTH
plan and initiate
gain patient buy in, d/c one agent at a time, taper meds likely to cause withdrawal symptoms, communicate plan to deprescribe with all care givers and healthcare professionals involved
deprescribing.org uses
PPIs, antihyperglycemics, antipsychotics, BZDs, cholinesterase inhibitors, memantine
monitor, support and document
degree of monitoring depends on medication being deprescribed, support may include non-pharm interventions, clearly document rationale and outcomes
