An overview of deprescribing
- 1. DE-PRESCRIBING – AN OVERVIEW A Seminar presented by NNAJI, AUGUSTINE CHUKWUKA DEPARTMENT OF CLINICAL PHARMACY & BIOPHARMACY SCHOOL OF POSTGRADUATE STUDIES UNIVERSITY OF LAGOS 1
- 2. Outline • Introduction • Justification • Objectives • Literature review • Pharmacist’s Role • Conclusion • References 2
- 3. Introduction • De-prescribing: “is a systematic process supervised by a healthcare professional that involves reviewing, tapering and withdrawing inappropriate medications within the context of an individual patient’s goals of care, level of functioning, life expectancy, values and preferences. The overall goal is to improve patient outcome’’. • Shared Decision Making • Inappropriate polypharmacy • Common in geriatrics and palliative care • Also useful in other group of patients (Scott et al., 2015; Ulley et al., 2019; Lee et al., 2021). 3
- 4. Introduction (cont’d) • Potentially Inappropriate Medicines (PIMs) use is considered one of the commonly encountered medication-related problems among the older population and in comorbidities. • Other Medication-related problems (MRPs) includes: - adverse drug reactions - interactions and ineffectiveness - improper drug selection and untreated conditions - excessive or inadequate dosing (Page et al., 2010; Lattanzio et al., 2012; Shah and Hajjar, 2012). 4
- 5. Introduction (cont’d) • Prevalence of PIMs: - Globally: Highly variable - In Portugal: 46.1% of PIMs in 757 patients (Simoes et al., 2019). - In South Africa: 29.6% of PIMs in 328 patients (Saka et al., 2019). - In Saudi Arabia: 57.6% of PIMs in 4073 patients (Alhawassi et al., 2019). • Prevalence of PIMs in Nigeria: Under-reported - South West (Ibadan): 30.3% of PIMs in 220 patients (Fadare et al., 2015). - South West (Ogun): 35.2% of PIMs 352 patients (Saka et al., 2019). - North West (Kano): 29.9% of PIMs in 244 patients (Abubakar et al., 2021). 5
- 6. Justification • Polypharmacy among older adults is common and consequently older patients are at higher risk of PIMs use. • PIMs use increases the risk of hospitalization, drug-related problems and other adverse health outcomes by two to three folds • Maximizing patient benefit and minimizing harm can be achieved through medication optimization reviews and de-prescribing (Scott et al., 2015; Alhawassi et al., 2019). 6
- 7. Objectives • To highlight categories of patients and medications to consider for de-prescribing. • To highlight some de-prescribing tools and steps • To present the benefits and harms of de-prescribing 7
- 9. Categories of patients for de-prescribing No Risk group Comments 1 Polypharmacy Increases risk of ADRs 2 Multi-morbidity Higher chances of PIMs 3 Renal disease May require dose adjustment 4 Multiple prescribers and transitions of care Increased risk of duplication (Steinman et al., 2014; Kua et al., 2019; Akande-Sholabi et al., 2020). 9
- 10. Categories of patients for de-prescribing (cont’d) No Risk group Comments 5 Limited life expectancy Changing goal of therapy 6 Poor adhering patients May be due to pill burden 7 Advanced age Predisposes to polypharmacy (Steinman et al., 2014; Kua et al., 2019; Akande-Sholabi et al., 2020). 10
- 11. Medication categories for de-prescribing 11 Class Examples Reasons 1 Benzodiazepines and benzodiazepine receptor agonists Zolpidem, Diazepam Physical and psychological dependence-,falls, impaired cognition, reduced alertness, 2 Proton pump inhibitors Pantoprazole Fractures, Clostridium difficile infections, vitamin B12 deficiency and hypomagnesemia 3 Cholinesterase inhibitors Donepezil, Galantamine Dizziness, confusion, headache, insomnia, agitation, weight loss and falls. (Park et al., 2017 ; Martin et al., 2018; Shrestha et al.,2020).
- 12. Medication categories for de-prescribing (cont’d) Class Examples Reasons 4 Anti-diabetic agents Insulins, glyburide Hypoglycemia 5 Antipsychotics Haloperidol, Risperidone, Olanzapine Metabolic disturbances, drowsiness, injurious falls 6 Nonsteroidal anti- inflammatory drugs Ibuprofen, Diclofenac Increased risk of bleeding (Park et al., 2017; Martin et al., 2018; Shrestha et al.,2020). 12
- 13. De-prescribing tools and criteria 13 Some de-prescribing criteria and guidelines 1. American Geriatrics Society Beers Criteria(AGS/Beers) 2. Screening Tool for Older Person’s Prescriptions (STOPP) criteria 3. Screening Tool to Alert Right Treatment (START) criteria 4. Improved prescribing in the elderly tool (IPET)/Canadian Criteria 5. Medication Appropriateness Index (MAI) (Tosato et al., 2014; AGS/Beers, 2019; Fick et al, 2019).
- 14. 5-step approach to effective de-prescribing Step 1: Comprehensive Medication History Step 2: Identify Potentially Inappropriate Medications Step 3: Determine if medications can be stopped and prioritize Step 4: Plan and initiate withdrawal Step 5: Monitoring, support and documentation 14 (Reeve et al., 2014; Scott et al., 2015; Lee et al., 2021).
- 15. Benefits of de-prescribing 15 • Helps to improve patient quality of life and overall health outcome • Reduction in the burden of medication • Reduction in the risk of falls • Could help improve and/or preserve cognitive function • Helps to reduce the risk of hospitalization and death • Facilitation of improved adherence and reduction in economic burden (Reeve et al., 2014; Potter et al., 2016; Garfinkel, 2018; Maust, et al., 2021).
- 16. Risks/harms of de-prescribing They include: • Adverse drug withdrawal syndrome • Pharmacokinetic changes • Pharmacodynamic changes • Return of the medical condition. (Reeve et al., 2015; Campins et al., 2017; Bloomfield et al., 2020). 16
- 17. Roles of the Pharmacist • Pharmacists play key role in de-prescribing by identifying unnecessary medications and working in collaboration with other healthcare providers to implement changes to drug regimen that best suits the patient • Studies have shown that medication review by pharmacists led to significantly lesser number of fall-risk medications and the number of falls in the elderly (Marvin et al., 2016). 17
- 18. Conclusion 18 • De-prescribing can be framed as a part of good clinical practice. • Shared decision making is critical for the success of de-prescribing • Regular patient review is required for successful de-prescribing. • Senior citizens and those with multi-morbidity may benefit more from de- prescribing. • In Nigeria, our healthcare team should collaborate towards establishing the prevalence of PIMs and thus develop a de-prescribing framework for clinical practice in Nigeria.
- 19. References • Abubakar, U., Tangiisuran, B., Kolo, M., Yamma, A.I., Hammad M.A and Sulaiman S.A.S. (2021) ‘Prevalence and predictors of potentially inappropriate medication use among ambulatory older adults in Northern Nigeria’, Journal of Drugs and Therapy Perspectives, 37(1), pp 94–99. Available at https://link.springer.com/article/10.1007/s40267-020-00800-3 • Alhawassi, T.M., Alatawi, W. and Alwhaibi, M. (2019) ‘Prevalence of potentially inappropriate medications use among older adults and risk factors using the 2015 American Geriatrics Society Beers criteria’ BMC Geriatrics 19(1), p154. Available at https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1168-1 • Akande-Sholabi, W., Ajilore, O.C., Showande, S.J. and Adebusoye, L.A. (2020) ‘Potential inappropriate prescribing among ambulatory elderly patients in a geriatric Centre in southwestern Nigeria: Beers criteria versus STOPP/START criteria’, Tropical Journal of Pharmaceutical Research,19(5), pp 1105-1111 DOI: 10.4314/tjpr.v19i5.29 19
- 20. References (cont’d) • American Geriatrics Society Beers Criteria® Update Expert Panel (AGS/Beers). (2019) ‘American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal of American Geriatric Society, 67(4): 674-694.doi: 10.1111/jgs.15767. • Bloomfield, H.E., Greer, N., Linsky, A.M., Bolduc, J., Naidl, T., Vardeny, O., MacDonald, R., McKenzie, L. and Wilt, T. J. (2020) ‘Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis’, Journal of Gen Internal Medicine, 35(11), pp 3323-3332. DOI: 10.1007/s11606-020-06089-2 • Campins, L., Serra-Prat, M., Gozalo, I., Lopez, D., Palomera, E., Agusti, C. and Cabre, M. (2017) ‘Randomized controlled trial of an intervention to improve drug appropriateness in community-dwelling polymedicated elderly people’, Journal of Family Practice, 34(1), pp 36–42. Doi.org/10.1093/fampra/cmw073 20
- 21. References (cont’d) • Duncan, P., Duerden, M. and Payne, R.A (2017) ‘Deprescribing: a primary care perspective’, European Journal of Hospital Pharmacy, 24(1): 37–42. Doi:10.1136/ejhpharm-2016-000967 • Fadare, J.O., Desalu, O.O., Obimakinde, A.M., Adeoti, A.O., Agboola, S.M. and Aina, F.O. (2015) ‘Prevalence of inappropriate medication prescription in the elderly in Nigeria: A comparison of Beers and STOPP criteria’, The International Journal of Risk Safety in Medicine, 27(4), pp 177-89. Doi: 10.3233/JRS-150660. • Fick, D.M., Semla, T.P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C.E., Pezzullo, L., Epplin, J.J., Flanagan, N. (2019) ‘Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal of American Geriatrics Society, 67(4), pp 674-694. Doi: 10.1111/jgs.15767. 21
- 22. References (cont’d) • Fick, D.M., Semla, T.P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C.E., Pezzullo, L., Epplin, J.J., Flanagan, N. (2019) ‘Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal of American Geriatrics Society, 67(4), pp 674-694. Doi: 10.1111/jgs.15767. • Garfinkel, D. (2018) ‘Poly-de-prescribing to treat polypharmacy’, Journal of Therapeutic Advances in Drug Safety, 9(1), pp 25–43. DOI: 10.1177/2042098617736192 • Kua, C. H., Mak, V.S.L. and Huey, L. S.W. (2019) ‘Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis’, Journal of American Medical Directors Association, 20(3), pp 362-372. DOI: 10.1016/j.jamda.2018.10.026 22
- 23. References (cont’d) • Lattanzio,F., Landi, F., Bustacchini, S., Abbatecola, A. M., Corica, F., Pranno, L. and Corsonello, A. (2012) ‘Geriatric conditions and the risk of adverse drug reactions in older adults: a review’, Drug Safety Journal, 35(1) pp 55–61. Doi:10.1007/BF03319103 • Lee, J., Negm, A., Peters, R., Wong, E. K. C. and Holbrook, A. (2021) ‘Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall- related complications: a systematic review and meta-analysis’, British Medical Journal, 11(2), pp e035978. DOI: 10.1136/bmjopen-2019-035978. • Martin, P., Tamblyn, R., Benedetti, A., Ahmed, S. and Cara, T. (2018) ‘Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-prescribe Randomized Clinical Trial’, The Journal of the American Medical Association, 320(18), pp 1889-1898. DOI: 10.1001/jama.2018.16131 23
- 24. References (cont’d) • Marvin, V., Ward, E., Poots A.L., Heard, K., Rajagopalan, A. and Jubraj, B. (2016) ‘Deprescribing medicines in the acute setting to reduce the risk of falls’, European Journal of Hospital Pharmacy, 24(1), pp10-15. http://dx.doi.org/10.1136/ejhpharm-2016-001003 • Maust, D.T., Strominger, J., Kim, H.M., Langa, K.M., Bynum S.C. (2021) J.P.W., Chang, C., Kales, H.C., Zivin, K., Solway, E. and Marcus, ‘Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US’, The Journal of the American Medical Association, 325(10), pp 952-961. DOI: 10.1001/jama.2021.1195. • Page, R.L., Linnebur, S.A., Bryant, L.L. and Ruscin, J.M. (2010) ‘Inappropriate prescribing in the hospitalized elderly patient: defining the problem, evaluation tools, and possible solutions’, Clinical Interventions in Aging, 7(5), pp 75-87. Doi: 10.2147/cia.s9564. 24
- 25. References (cont’d) • Park, H.Y., Park, J.W., Song, H.J., Sohn, H. S. and Kwon, J. (2017) ‘The association between polypharmacy and dementia: a nested case-control study based on a 12-year longitudinal cohort database in South Korea’, PLoS One Journal, 12(1), p e0169463. Doi:10.1371/journal.pone.0169463. • Potter, K., Page, A., Clifford, R. and Etherton-Beer, C. (2016) ‘Deprescribing: a guide for medication reviews’, Journal of Pharmacy Practice and Research,46(4), pp 358-367. Doi.org/10.1002/jppr.1298 • Reeve, E., Shakib,S., Hendrix, I., Roberts, M.S., Wiese, M.D. (2014) ‘Review of deprescribing processes and development of an evidence- based, patient-centred deprescribing process’, British Journal of Clinical Pharmacology, 78(4), pp 738-747 https://doi.org/10.1111/bcp.12386 25
- 26. References (cont’d) • Reeve, E., Gnjidic D., Long J. and Hilmer, S. (2015) ‘A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice’. British Journal of Clinical Pharmacology, 80(6), pp 1254-68. DOI: 10.1111/bcp.12732. • Shah, B. M. and Hajjar, E. R. (2012) ‘Polypharmacy, adverse drug reactions, and geriatric syndromes’, Journal of Clinical Geriatric Medicine, 28, 173–186. Doi:10.1016/j.cger.2012.01.00 • Saka, S. A., Oosthuizen, F. and Nlooto, M. (2019) ‘Potential inappropriate prescribing and associated factors among older persons in Nigeria and South Africa’, International Journal of Clinical Pharmacy, 41(1), pp 207–214. Available at https://link.springer.com/article/10.1007/s11096-018-0770-1 26
- 27. References (cont’d) • Shrestha, S., Poudel, A., Steadman, K. and Nissen, L. (2020) ‘Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review’, British Journal of Clinical Pharmacology, 86(10), pp1931-1945. Doi: 10.1111/bcp.14113. • Scott, I. A., Hilmer, S.N., Reeve, E., Potter, K., Couteur, D.L., Rigby, D., Gnjidic D., Mar, C.B.D., Roughead, E.E., Page, A., Jansen, J. and Martin J.H. (2015) ‘Reducing inappropriate polypharmacy: the process of deprescribing’, The Journal of the American Medical Association, 175(5), pp 827-834. Doi:10.1001/jamainuternmed.2015.0324. • Simoes, P.A.S., Santiago,L.M., Maurício, K. and Simoes, J.A. (2019) ‘Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study’, Journal of Patient Preference Adherence,13(1): pp1569–1576. doi:10.2147/PPA.S219346 27
- 28. References (cont’d) • Steinman, M.A., Miao, Y., Boscardin,W.J., Komaiko, K.D.R., Schwartz, J.B. (2014) ‘Prescribing quality in older veterans: a multifocal approach’. Journal of General Internal Medicine, 29 (10), pp 1379-86.. Doi: 10.1007/s11606-014- 2924-8 • Tosato, M., Landi, F., Martone, A.M., Cherubini, A., Corsonello, A., Volpato, S., Bernabei, R., Onder, G. (2014) ‘Potentially inappropriate drug use among hospitalized older adults: Results from the CRIME study’, Age and Ageing Journal, 43(6), pp 767-73. Doi: 10.1093/ageing/afu029. • Ulley, J., Harrop, D., Ali, A., Alton., S. and Davis, S. F. (2019) ‘Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review’, BMC Geriatrics, 19(1), p 15. DOI: 10.1186/s12877-019-1031-4. 28
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