deprescribing when less is more · ibuprofen (advil®), celecoxib (celebrex®) • some...

Deprescribing – when less is more

Barbara Farrell PharmD, FCSHP

May 2018

19 June 2018

Outline

• Why we use medications

• The risks of polypharmacy

• Tracking our medication use

• When to consider deprescribing

• Talking to your health care provider about polypharmacy and deprescribing

• Deprescribing at Bruyère Research Institute

• The Canadian Deprescribing Network

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Medications can:

• Treat symptoms

• Slow the progression of disease

• Reduce the risk of complications from disease

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Are seniors on too many meds?

2 out of 3 Canadians over the age of 65 take at least 5 different prescription medications

1 out of 4 Canadians over the age of 65 take at least 10 different prescription medications

Canadian Institute for Health Information. 2014. Drug Use Among Seniors on Public Drug Programs in Canada.

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What’s it costing us?

• $419 million spent on potentially inappropriate medications (PIMs)

• $1.4 billion estimated for incremental health care expenditure due to PIMs

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Polypharmacy

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• Polypharmacy: more medications than needed, or for which harm outweighs benefit

• Increases risk of: – Adverse drug reactions, drug interactions

– Falls, fractures

– Functional and cognitive decline

– Nonadherence

– Hospitalizations and higher healthcare costs

• Especially for the elderly who handle and respond to drugs differently, are often frail and not represented in research

As we get older

• The brain becomes more sensitive to drug effects

• Some medications stay longer in our body because we have less muscle and more body fat

• Our liver and kidneys do not process medications as efficiently as when we were younger

• Our body contains less water and medications can become more concentrated

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Which medications affect the bladder?

• Cholinesterase inhibitors: e.g. rivastigmine (Exelon®), donepezil (Aricept®)

• Opioids: e.g. codeine, morphine • Benzodiazepines: e.g. lorazepam (Ativan®) • Tricyclic antidepressants: e.g. amitriptyline (Elavil®) • Nasal decongestants • Antihistamines • Hormone replacement drugs: e.g. (Estrace®) • Antipsychotics: e.g. chlorpromazine (Largactil®) • Some diuretics: e.g. Furosemide (Lasix®) • Some non-steroidal anti-inflammatory drugs (NSAID): e.g.

ibuprofen (Advil®), celecoxib (Celebrex®) • Some antihypertensive drugs: e.g. nifedipine (Adalat®), amlodipine

(Norvasc®) • Some blood pressure medications: e.g. ACE inhibitors such as

enalapril (Vasotec®), ramipril (Altace®)

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Which medications affect memory?

• Benzodiazepines/sedatives/sleeping pills: e.g.

alprazolam (Xanax®), zolpidem (Ambien®), lorazepam

(Ativan®)

• Antipsychotics: e.g. quetiapine (Seroquel®), risperidone

(Risperdal®), aripiprazole (Abilify®)

• First generation antihistamines: e.g. diphenhydramine

(Benadryl®), brompheniramine (Dimetapp®)

• Opioids: e.g. Oxycodone (OxyNeo®, Percocet®), Meperidine

(Demerol®), Codeine (Tylenol NO. 1®, NO. 2®, NO. 3®)

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Which medications increase the risk of falls?

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Sources: de Jong et al. 2013. Therapeutic Advances in Drug Safety.

4(4): 147-154 & Huang et al. 2012. Drugs & Aging 29(5):359-76

Risk of Drug-Drug interactions

Low risk

2 5-7 8-10

4-fold

greater risk

8-fold

greater risk

Number of medications

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Johnell, K., Klarin, I. 2007.

Drug Safety; 30 (10): 911-

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Medications may have unpredictable effects when they interact with each other. More medications means a higher chance of interactions.

How does polypharmacy happen?

• More medications than ever before

• People are living longer (and acquiring more diseases with more medications)

• Guidelines tell prescribers when to start drugs but not when to stop them

• Fear of ‘rocking the boat’

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Vintage ad for the benzodiazepine oxazepam (Serax®)

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In the late 1970s, benzodiazepines are the most prescribed medication in the world. Women are generally more frequent consumers.

Benzodiazepines

• Diazepam, better known as Valium®, are approved for use (1963)

• Prescribed to relieve anxiety and facilitate sleep

• Even the occasional use can cause multiple harmful effects

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What a drag it is getting old ‘Kids are different today’, I hear ev’ry mother say Mother needs something today to calm her down And though she’s not really ill There’s a little yellow pill She goes running for the shelter of a mother’s little helper - “Mother’s Little Helper” by The Rolling Stones, 1966

We all have a story: Johanna Trimble

Could this be you or a loved one?

• Side effects • Drug interactions • Prescribing cascades • Being ‘compliant’ • Falls • Hip fractures • Confusion • Emergency room

visits • Hospitalizations • Death

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Tracking your medication use

• Using the blank medication chart, fill in:

– The name of each of your medications

– Reason/goal

– When it was started and by who

– How to take it

– Intended duration (life-long? Or for certain timeframe?)

– Monitoring parameters

– Side effects to watch for

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Questions

• Put up your hand if you could fill in part of the chart

• Leave your hand up if you feel confident you could fill in every section of the chart

• What information was hard to recall?

• Why?

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What is deprescribing?

Deprescribing is the planned and supervised process of reducing or stopping medications that may no longer be of benefit or may be causing harm.

Deprescribing is part of good prescribing – backing off when doses are too high, or stopping medications that are no longer needed or might be causing harm.

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Steps in deprescribing

1. Compile a medication history

2. Identify potentially inappropriate medications, those with less evidence for benefit or those with harm

3. Assess each medication for eligibility for deprescribing

4. Prioritize medications for deprescribing

5. Develop a plan for tapering and monitoring

6. Monitor, support and document care

With the patient…

Deprescribing safely

• Monitor for adverse drug withdrawal events – Symptoms or signs caused by the removal of a drug:

1. Physiological - tachycardia (beta-blocker); rebound hyperacidity (PPI)

2. Symptoms of underlying condition - arthritis pain after stopping an NSAID

3. New symptoms - excessive sweating with stopping SSRI

– Increased risk with: • Longer duration, higher doses, short half-life • History of dependence/abuse • Lack of patient ‘buy-in’

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What can you do?

• Educate yourself about the medications you are taking and why

• Talk to your health care provider about deprescribing options and alternate therapies

• Spread the word about deprescribing to friends and family, advocacy groups and government representatives

• Be prepared and aware throughout your deprescribing plan

Ask questions, stay informed, be proactive, and participate in making smart choices!

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MEDSTOPPER

medstopper.com

• Bruyère Deprescribing Guidelines Research Website: www.deprescribing.org • Canadian Deprescribing Network Website: www.deprescribingnetwork.ca • Choosing Wisely Canada Website: www.choosingwiselycanada.org • Institute of Safe Medication Practices Canada Website: www.ismp-canada.org

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Organizations with resources that can help

Alternatives to sleeping pills/sedatives

Sleep hygiene, relaxation and cognitive behavioural therapy to achieve a regular and restorative sleep/wake cycle

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Brochure available at:

www.deprescribingnetwork.ca/useful-resources

The work of the Bruyère Deprescribing Guidelines team

• Providing healthcare providers with evidence based guidelines and algorithms that help them help you decide when and how to reduce certain medications

• 5 algorithms available: Benzodiazepines, Antipsychotics, Proton Pump Inhibitors, Cholinesterase Inhibitors and Antihyperglycemics (www.deprescribing.org)

• Spreading the word: reaching out to community groups, engaging policy makers

• Networking with likeminded healthcare providers and organizations (locally and nationally)

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The Bruyère Deprescribing Research Program

Component Funder Timeline

Developing, implementing and evaluating evidence-based deprescribing guidelines

Government of Ontario (HSRF) and CIHR

2013-2016

Community pharmacists as catalysts for deprescribing

Canadian Foundation for Pharmacy

2016-2017

Spreading deprescribing knowledge, tools, resources and engaging stakeholders

Centre for Learning, Research and Innovation

2017-2019

Building capacity for deprescribing development, use and education

CC-ABHI – KMP2 2017-2018

A multi-method approach to exploring prescribing cascades

CIHR 2016-2020

Deprescribing Initiatives using community engagement

Government of Ontario (HSRF)

2017-2021

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Can someone add the front page of the PPI pamphlet here please? For some reason, we only have the back page (on next slide)

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Knowledge mobilization

• Website http://deprescribing.org

• Tools

• Publications

• Social media

• Symposium

• Presentations

• Networking

– CADTH, CIHI, Health Canada, MOHLTC, IHI etc

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Twitter (@deprescribing)

The Canadian Deprescribing Network

The Canadian Deprescribing Network is a group of health care leaders, clinicians, decision-makers, academic researchers and patient advocates working together to mobilize knowledge and promote the deprescribing of medication that may no longer be of benefit or that may be causing harm.

Governments

Research & innovation

Health

information

systems

Health-related

organizations

Health care

providers

Individual patients,

caregivers &

the public

Clinical decision

making

Health & social policies

Patient

empowerment

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The Canadian Deprescribing Network

Goals:

• Raise awareness and decrease the inappropriate use of medications for seniors by 50% by 2020.

• Ensure access to safer drug and non-drug therapies.

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Take home messages

• Polypharmacy in the elderly carries numerous risks

• Deprescribing is feasible and safe when supervised and monitored

• All deprescribing algorithms and ‘steps’ include: evaluating need for ongoing indication of each medication, weighing benefit and harm of continuing, developing and communicating a plan for deprescribing, carrying out deprescribing actions and monitoring

• It’s OK to talk to your prescriber about when deprescribing would be useful

• Remember to use non-drug approaches for symptom management when you can

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Bruyère Deprescribing Guidelines Research Team

Website: deprescribing.org

Email: deprescribing@bruyere.org

Social: Twitter @deprescribing Facebook @deprescribing.org

Canadian Deprescribing Network

Website: deprescribingnetwork.ca

Email: info@deprescribingnetwork.ca

Social: Twitter @DeprescribeNet Facebook @deprescribingnetwork

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Funding and Support

Deprescribing guidelines developed with funding from the Government of Ontario*, the Ontario Pharmacy Research Collaboration and Canadian Institutes of Health Research

*The views expressed in this presentation are the views of the author(s)/presenter(s) and do not necessarily reflect those of the Province.