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PH4703-Practical therapeutics > Deprescribing > Flashcards

Deprescribing Flashcards

1
Q

Medicines optimisation

A
  • Medicines optimisation: the safe and effective use of medicines to enable to best possible outcome
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2
Q

What is polypharmacy

A
  • Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
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3
Q

Definitions

Appropriate Polypharmacy, PIP

A
  • Appropriate polypharmacy- Is the prescription beneficial to a patient e.g. the combination of medicines prescribed following a myocardial infarction
  • Potentially Inappropriate Polypharmacy (PIP)
    • Multiple medicines on a long term basis
    • Without adequate review
    • Multiple prescribers
    • Many organisations
    • Inappropriate polypharmacy is NOT just about taking multiple medications- optimise medicines e.g. titrating BB in HF to the max tolerated dose
    • Harm outweighs benefits
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4
Q

Prescribing cascade

A
  • Prescribing cascade leads to polypharmacy
  • Potentially inappropriate polypharmacy is the prescribing of multiple medicines inappropriately, or where the intended benefit of the medicine is not realised
  • Inappropriateness of polypharmacy should be judged on a case by case basis
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5
Q

Causes of polypharmacy

Complex and multifactorial

A
  • Growth in evidence-based medicines
  • Proliferation of guidelines
  • Longevity
  • Multimorbidity
  • Focus on disease prevention
  • Improved access to treatment
  • Fragmented care and transfer of care
  • Increasing expectation from patients and families
  • Non-adherence
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6
Q

Setting the scene

Did you know

A
  • One-quarter of the population has a long-term condition
  • One-quarter of people over 60 have 2 or more long-term conditions
  • With an ageing population, the use of multiple medicines (known as polypharmacy) is increasing
  • Between 30-50% of medicines prescribed for long-term conditions are not taken as intended
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7
Q

Definition

A
  • De-prescribing is the planned and supervised process of DOSE REDUCTION or STOPPING of a medication that may be causing HARM or no longer providing BENEFIT
  • There are lots of factors to consider as part of the process- patient involvement is integral to successful de-prescribing
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8
Q

Alternatives to prescribing

A
  • Social prescriber
  • Link worker
  • Community response team
  • Community therapy team
  • Leisure activities
  • Exercise referral
  • Dementia forward and other groups
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9
Q

7 steps to appropriate polypharmacy

A
  • Agree and share medicine plan
  • Right medicine
  • Unnecessary medicine
  • Effective medicine
  • Harmful medicine
  • Cost-effective medicine
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10
Q

Considerations for de-prescribing

A
  • Symptomatic treatments- the benefits of treatments should clearly outweigh the associated harms- a medicine, which slightly improves symptoms scores in a population, is only worthwhile to the individual if it effectively improves the patients QoL. If this cannot be demonstrated during a short therapeutic trial, it should be stopped
  • Preventative treatments- if a patient has multiple or serious degenerative conditions that are expected to reduce longevity or diminish QoL, long term treatment strategies may no longer be relevant
    • Preventative treatment goals should always be explained and understood by the individual and if appropriate their family or carer
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11
Q

Factors to consider

A
  • The patient’s wishes
  • Clinical indications and expected benefit of each drug
  • Appropriateness, with respect to current guidelines
  • Adherence
  • Adverse drug reactions
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12
Q

How to deprescribe

A
  • A 5 step process can be used when stopping medicines (initially as a trial)
  1. Adherence check
  2. Identify any PIP
  3. Determine whether PIP can be stopped
  4. Plan the withdrawal regimen; reduce to stop one medicine at a time
  5. Check for benefit or harm after each medicine has been reduced or stopped
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13
Q

Target groups

A
  • Multi-morbidity patients- presence of two or more long-term health conditions
  • Polypharmacy- patients taking large numbers of medicines (>15)
  • Elderly (>75yr) frail patients
  • Housebound patients
  • Patients with indications of shortened life expectancy/end of life
  • Vulnerable patients
  • Decline in hepatic function/renal function
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14
Q

Special groups

A
  • Impact of polypharmacy in patients with frailty
    • Adults who are frail lack the reserve to deal with AE
    • Guidelines may not take the presence or absence of frailty into account when making recommendations
    • This places frail adults at particular risk of adverse drug reactions, interactions or rapid deterioration if necessary medication is not optimised
  • De-prescribing in frailty and end of life
    • Consider stopping preventive chronic disease medication and reducing any potentially inappropriate polypharmacy
    • Discuss the potential impact with patients and their carers and with the MDT prior to making a decision
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15
Q

Frailty Reviews

A
  • Medicines likely to cause adverse drug reactions in patients with frailty (this list is not exhaustive)
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Diuretics
  • Angiotensin-converting enzyme inhibitors (ACE–Is) (but these may be appropriate in heart failure, Angiotensin II receptor blockers (ARBs), Beta-blockers
  • Medicines that affect the central nervous system e.g. antidepressants (particularly tricyclic antidepressants), antipsychotics, benzodiazepines, opioids, and other analgesics.
  • Dihydropyridine calcium channel blockers e.g. nifedipine
  • Digoxin at a dose of over 125 micrograms daily
  • Anticholinergics (see Appendix 5 for drugs that affect the cholinergic system below)
  • Phenothiazines e.g. prochlorperazine.
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16
Q

Steps to deprescribing

A
  • Ascertain all drugs the patient is taking and the resons for each one
  • Consider the overall risk of drug-induced harm
  • Assess each drug for its eligibility to be discontinued
  • Prioritise drugs for discontinuation
  • Implement and monitor drug discontinuation regimen
  • Support the patient
  • Document the changes
17
Q

Risks of polypharmacy

A
  • Increased risk of
    • Falls
    • Delirium/confusion
    • Lethargy
    • Depression
    • Adverse effects
    • Hospital admissions
    • Death
    • Increased financial burdens
18
Q

Barriers to deprescribing

A
  • Multiple prescribers- nurse/doctors/pharmacists/ANPs
  • Secondary care/ Primary care (joint care)
  • New patient to this health care provider
  • Unclear duration of treatment
  • Lack of continuous medication list review
  • Fear of adverse drug withdrawal effects
  • The pressure to prescribe due to guidelines
  • Family insists
  • Patients view- Montgomery case
  • Physician giving up on them- DNAR patients
  • Patients are afraid to stop medications they have taken for years- habit
19
Q

Opioid burden

A
  • Prescribing stabilised in recent years, but equivalence increased
  • Chronic non-cancer pain: harm outweighs benefit at 120mg oral morphine equivalence/24hrs
  • Study links high dose opioids to increased healthcare use, morbidity and mortality
  • Define indication and duration on initiation
  • MDT approach
  • Benefit of pharmacist-led medication review
  • Review at each request
20
Q

Falls risk and frailty

A
21
Q

Tools for de-prescribing

A
  1. impact tool- Improving medicines and polypharmacy appropriateness tool
  2. Stopp-start- adapted guidance to Dudley patients
  3. Prescqipp- drugs to review for optimised prescribing list
  4. No tears- 10-minute medication review guidance
  5. Med stopper tool- Canadian tool encompasses beers criteria
  6. Scottish polypharmacy guidance- includes 7 steps to managing polypharmacy, ACB tablets, high risk drugs and end of life de-prescribing
22
Q

IMPACT tool

A
  • Improving medicines and polypharmacy appropriateness clinical tool
  • The information in the tool should be used as a pragmatic decision aid, in conjunction with other relevant, patient-specific data. If therapy is considered appropriate, it should be continued
  • Medicines with medium or high clinical and/or cost risk are highlighted and may be considered as a priority to focus on
  • When speaking to patients about their medicines, HCP’s should review whether therapy is appropriate and still being adhered to
23
Q

Stop-start tool

A

STOPP/START Toolkit STOPP/START is a screening tool of older people’s prescriptions (STOPP) and a screening tool to alert to right treatment (START); the criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was completed in 2015.

•

The STOPP START is a detailed aid to medication that might

be either inappropriate (STOPP) or worth starting in the elderly (START). The clinical risk classifies the risk of continuing therapy based on maintenance doses. The cost risk identifies areas where total spend in primary care is high

24
Q

PrescQipp

A

PrescQIPP Drugs to Review for Optimised Prescribing list (DROP-List)

  • https://www.prescqipp.info/droplist
  • The DROP-List is an accumulation of medicines that are

regarded as a low priority, poor value for money or medicines for which there are safer alternatives. Some of the NICE ‘do not do’ recommendations have been incorporated into the DROP-List. The list also includes medicines that could be considered for self-care, with the support of the community pharmacist. Reviewing medicines on the DROP-List will support the reduction of inappropriate polypharmacy

25
Q

NO-TEARS tool

A
26
Q

MedStopper Tool

A
  • The MedStopper web app is largely based on expert opinion from renowned evidence based medicine experts and de- prescribing experts.

The medical tool includes other de-prescribing resources such as Beers and STOPP criteria as well as the validated Edmonton Frail Scale.

27
Q

Scottish Polypharmacy Toolkit

A
    1. What matters to the patient?
      1. Identify essential drug therapy. Does the patient take

unnecessary drug therapy?

  1. Are the therapeutic objectives achieved?
  2. Does the patient have Adverse Drug reactions (ADRs) or side

effects to the medication? Or are they at risk of side effects?

  1. Does the patient know what to do if they are unwell?
  2. Is the drug cost effective?
  3. Is the patient willing and able to take the drug therapy as

intended?

28
Q

Law and ethics of deprescribing

A
  • When de-prescribing is undertaken in partnership with the patient, supported by knowledge, skills and experience of patients and clinicians and the patient’s values and preference-based on evidence-based practice- the law creates no barrier to de-prescribing
29
Q

Law and ethics

A
  • Duty of care
  • Bolam test- risk versus benefit- the majority of practitioners rule applies
  • Montgomery case- now what a reasonable patient would expect from a consultation (How do we know if patients are thinking)
  • BRAN- Benefits Risks Alternatives Nothing-
  • Need to ensure the patient is in agreement with actions – “informed consent”
  • 7 steps Scottish guidance – considers patient’s wishes first – patient-centric approach to consultation, what is the impact of starting/stopping medicines
  • Share the burden of uncertainty – statistically it will help - the decision always carries clinical uncertainty
30
Q

Top 10 drugs for deprescribing

A
  • Opioids
  • BZ
  • Anticholinergics
  • Anti-HTN
  • PPI
  • NSAIDs
  • Statins
  • laxatives
  • Prophylactic Antibiotics
  • Bisphosphonates
31
Q

Patient-centric approach

A
  • GPhC guidance- standard 1- duty of care to patients
  • Hello my name is- campaign- building rapport and trust in patients
  • Assess patient- why have they come to you
  • Define their context and overall goals
  • Equally, need a list from patient too (3 legged stool)
  • Use your clinical judgement to decide whether drugs will/should be stopped/started
  • Use TEACHBACK method- to check I have explained it properly can you tell me what your next steps are
  • Communication- need written instructions
32
Q

Tackling polypharmacy through med review

A
  1. Identify patient cohort to review
  2. Review all current medicines and identify indication
  3. General housekeeping
  4. Assess prescription frequency to identify over/underuse
  5. Optimisation and rationalisation
  6. Identify medicines to be discontinued, substituted or reduced
  7. Discuss deprescribing plan in partnership with patient and carers (written and verbal)
  8. Identify opportunities for cost-effective prescribing
  9. Follow up
33
Q
A

PH4703-Practical therapeutics (36 decks)

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