Lecture 14 - deprescribing Flashcards
what is involved in the management of complex patients?
multi morbidity, frailty and polypharmacy
what is multi morbidity ?
multi morbidity is the coexistence of two or more diseases or illnesses in the same individual simultaneously accompanied by physical and functional decline
what is frailty ?
frailty can be defined as age-related state of weakness and fragility that causes the patients physical and mental condition to deteriorate. it negatively affects body systems which eventually impair the daily activities and affect the quality of life
what is frailty syndrome?
falls, functional decline, immobile, delirium, cognitive decline, incontinence, susceptibility to side effects of medication
what is the definition of polypharmacy?
the use of more medications that are needed or for which harm outweighs benefit. particular risk for older people because they respond to drugs differently, are often frail, and are not typically represented in research
what can polypharmcy increase the risk of ?
drug interactions and side effects,
trouble taking medication as directed,
body not moving as well as it should,
mind not working as well as it should,
falling/ fractures,
hospital admission
what are triggers for deprescribing?
no indication,
no longer aligns with goals of care or life expectancy, inappropriate medications for geriatric patients, adverse drug events,
prescribing cascades,
non-adherence,
patient preference,
palliative care/ end of life
what are benefits for desprescribing?
fewer false and fractures,
fewer medication related cooers and improved adherence
reduced referral to acute services
improved condition
better quality of life
what are common drug for deprescribing ?
PPI,
BENZOS,
antimuscarinics,
antipsychotics for patients with dementia, cholinesterase inhibitors,
NSAIDs,
opioids,
antihyperglycemias
why are PPIs potential for deprescribing ?
increased risk fo fractures, c.diff, pneumonia, interstitial nephritis.
often started without a clear indication or continued despite symptom resolution.
initial trial should be 8 weeks for most common indications,
taper higher doses,
abrupt discontinuation causes risk of failure
continued if used for NSAID induced peptic ulcer risk
why are Benzes and z drugs potentials for deprescribing?
high risk of psychomotor impairment,
falls and cognitive impairment.
not first line for anxiety or insomnia.
KEY is patient education and slow taper to avoid withdrawal: 5-10% every 2 weeks.
Alternatives are SSRI, SNRI, CBT, sleep hygiene and melatonin
why are antimuscarinics potentials for deprescribing?
highly anticholinergic, often continued despite limited or no benefit, non-pharmacological interventions are 1st line: behavioural toileting interventiosn
why are antipsychotics for patients with dementia common for deprescribing?
no clear evidence for benefit and increased risk of mortality, EPS and falls.
Unlikely to benefit “agitated” behaviours
Taper: slow reduction (25%) – review after a week
Behavioural and environmental interventions are first-line
Alternatives: cholinesterase inhibitors, SSRIs
Reserve for patients with problematic psychosis
why are cholinesterase inhibitors potential for deprescribing?
only indicated for dementia,
very modest benefit for cognition and functional status,
adr: bradycardia, diarrhoea, anorexia/ weightless, urinary incontinence, nightmares.
deprescribe: if significant decline while on treatment, severe/ end-stage dementia, ADRs
What are some adverse effects of NSAIDs that can be reason for deprescribing?
Increased blood pressure
Peripheral oedema
Chronic heart failure exacerbation
GI bleeds
Risk of AKI or progression of CKD
perp over 75 and concomitant use os steroids, anticoagulants or SSRI are more susceptible to GI bleeds by NSAID cause
why are opioids potentials for deprescribing?
little evidence to support use in OA or chronic low back pain.
risk of constipation, delirium, sedation, falls unintentional overdose.
Desprescribe if no improvement in pain or function, of if ADRs.
Decrease by 10% per week. alternatives are topical NDSAIDs, TENS, physio, weight loss and steroids
why are antihyperglycemias potentials for deprescribing?
higher HBA1C targets in older adults: 7-8% or higher.
consider time to benefit for tight control and risk of hypoglycaemia.
desprescribe starting with drug most likely to cause hypoglycaemia and drugs with lowest HbA1c lowering potential.
What are some potential reasons for polypharmacy becoming more common?
More medications available now
People live longer
Increased hospital admissions (with many prescribers who start medicines)
A culture of adding a medication before trying a non-drug solution (e.g. diet and exercise)
Barriers for deprescribing
Medical culture of prescribing
Clinical inertia
Low self-efficacy
Low feasibility (time and workload restraints)
What does clinical inertia mean?
Lack of treatment intensification in a patient not at evidence-based goals for care (despite awareness of the guidelines)
Name the 5 steps of deprescribing
Step 1 - review and reconcile medications
Step 2 - risk vs benefit assessment for each medication
Step 3 - assess eligibility for discontinuation
Step 4 - prioritise drug discontinuation
Step 5 - discontinue medications and implement monitoring protocol
What needs to be assessed in step 1 of deprescribing?
All prescribed and OTC medications
Access indication
Assess adherence
How can the risk vs benefit be assessed for each medication (step 2)?
Apply a patient-centred approach
ADRs, drug interactions, drug-disease interactions
Use explicit tools (e.g. STOPP criteria)
True or false - assessing ease of discontinuation, risk of adverse drug withdrawal events, and taking into account preferences are all part of step 4
true
