learning to deprescribe drugs, english version

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enrique gavilán general practitioner

research department

polypharmacy laboratory

VI jornadas uso adecuado medicamentos

Plasencia 3 nov 2011

www.polimedicado.com / enrique.gavilan@yahoo.es

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  what is “deprescribing”?

  how to deprescribe?

  what´re the basis?

  how to desprescribe? who? by whom?

  does it works?

  what´re the risk / barriers / threats?

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  discontinuation

  drug removal / cessation

  drugectomy

  from polypharmacy to oligopharmacy

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cut off

pruning logging

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extirpation

+ gotic deco

minimalism

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therapeutic retirement

How? Fernandez did not come to work because he´s been buried? Well, I hope he do not forget to bring a certificate!

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deprescribing

following up

supplying

prescribing

indicating

diagnosing

therapeutic chain

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deprescribing prescribing

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  process of adaptation of drug regimen: tappering, replacing, eliminating drugs

  must take in consideration the scientific evidence, social and physical function, comorbidity, quality of life and patient´s preferences

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1.  review, review and again review

2.  reconsider therapeutic plan

3.  taper off, eliminate, substitute

4.  agree with the patient / caregiver

5.  follow up

Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51. Bain KT, et al. JAGS. 2008;56:1946-52. Woodward MC. J Pharm Pract Research. 2003;33:323-8.

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  review complete list of drugs

  be careful with over the counter drugs, naturopathics, non solid drugs

  medication reconciliation in medical transitions

  poor congruence with patient (58%)

Bikosky RM et al. JAGS. 2001;49:1353-7

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Holmes H, et al. Arch Intern Med. 2006;166:605-9

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Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51

  review the indication (active?, goals?, time to benefit?)

  analize the compliance degree

  detect adverse effects (present and risk)

  detect drug-drug and drug-disease interactions

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  no longer used drugs

  drugs for inactive or cured diseases

  those that caused adverse effects

  those that pottentially would cause relevant harms

  vicious drug waterfalls

Woodward MC. J Pharm Pract Research. 2003;33:323-8

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  Beers criteria

Examples:

-  digoxin, 0,25 mg/d, in heart failure

-  amitriptiline –anticholinergic and sedative properties-

-  long life benzodiazepines –fall risk and sedation-

Fick DM, et al. Arch Intern Med. 2003;163:2716-24

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  STOPP-START criteria Examples:

-  thiazides if history of gout

-  NSAID if uncontrolled HBP, renal failure or gastric bleeding

-  bladder antimuscarinics if history of dementia or glaucoma

Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46:72-83

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Maddison AR, et al. Prog Palliat Care. 2011;19:15-21

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  explaining and involving

  talking, informing, and, above all, listening

  preferences, expectations, beliefs

  adapt rythm to real posibilities

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  enhancing therapeutic adherence

  highlighting achievements

  supporting

  detecting recurrence or worsening symptoms

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  inappropriate polypharmacy as a public health problem

  absence of scientific evidence for certain drugs

  ethics criteria

  patient´s preferences

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Wilcox SM, et al. JAMA. 1994;272:292-6. Rollason V, Vot N. Drugs Aging. 2003;20:817-32

  40% of institutionalized & 25% of outpatient elderly has at least one inappropriate drug

  20% >70 years use 5 or more drugs

  difficult adherence, adverse effects, interactions, falls, morbidity, hospital admissions…

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Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31

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N = 339. Age > 80 y Jyrkkä et al. Drugs Aging. 2009; 26:1039-48

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are there elderly in clinical

studies?

what tells the

studies? and the

guidelines?

are there evidences?

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Lee PY, et al. JAMA. 2001;286:708-13

60-64 65-69 70-74 75-79 80-84 85-89 90-94

10

20

30

%

patients included in clinical trials

general population with dementia

age (years) Schoenmaker N, Van Gool WA. Lancet Neurol. 2004;3:627-30

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RR = 0.82 (0.69-0.99) NNT = 46 (637- 24)

HYVET Study. Beckett NS, et al. NEJM. 2008;358:1887-98

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Carey EC, et al. JAGS. 2008; 56:68–75

•  dependence personal hygiene: 1 point •  dependence in dressing: 1-3 points •  malignant disease: 2 points •  congestive heart failure: 3 points •  COPD: 1 point •  renal failure: 3 points

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•  congestive heart failure requiring treatment with a diuretic or ACO inhibitors •  renal failure (serum creatinine > 150 µmol/l) •  condition expected to severely limit survival, e.g. terminal illness •  clinical diagnosis of dementia •  resident in a nursing home (dependence) •  unable to stand up or walk …

clinicaltrials.gov/

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Van Bemmel T, et al. J Hypertens. 2006;24:287-92

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Iyer S, et al. Drugs Aging. 2008;25:1021-31

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Walma EP, et al. BMJ 1997;315:464–8

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Shepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7

N = 5804, 70-82 y

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The fallacy of cheating death has been promulgated by the apostles of altered life-stile. In their enthusiasm,

they have failed to stress that escaping death from myocardial infarction allows the possibility of

dying from cancer, stroke or Alzheimer Disease

Mc Cormick JS, Skrabanek P. Lancet. 1984;2:1455-6

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Hello, guy! How well you've come!

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Emslie C, et al. Coronary Health Care. 2001;5:25-32 Mangin D, et al. BMJ. 2007;335:285-7

  if it occurs in young patients: fast death, without suffering

  in the elderly: a natural dying, “a good way of dying"

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•  ibandronate, etidronate no studies in this age group

alendronate only one trial that includes >80 y women: RRR non vertebral fractures 46% (not as end point) (Pols 1999)

•  risedronate -  secondary prevention: RRR in morphologic vertebral fractures 81%, no effect on non-vertebral (Boonen 2004) - low risk primary prevent.: no effect hip fracture (McClung 2001)

•  zoledronate - secondary prevention, 55% >75 y: RRR any new fracture 5%, no effect on hip fracture (Lyles 2007) - primary prevention, 37% > 75 y: RRR morphologic vertebral fractures 70%, 41% on hip fracture (Black 2007)

Inderjeeth CA. Bone. 2009;44:744-51. Parikh S. J Am Geriatr Soc. 2009;57:327–34. Chua WM. Ther Adv Chonic Dis. 20011;2:279-86

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McClung MR, et al. NEJM 2001;344:333–40

RR = 0.6 (0.4–0.9), p = 0.009 RR = 0.8 (0.6–1.2), p = 0.35

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application of NOF guidelines to general population estimated that at least 34% of US white men aged

65 years and older and 49% of those aged 75 years and older would be recommended for drug

treatment

Donaldson MG, et al. J Bone Mineral Res. 2010;25:1506–11

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Black DM, et al. JAMA. 2006;296:2927-38

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Lai SW, et al. Medicine. 2010;89:295-99

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Boyd CM, et al. JAMA. 2005; 294:716-24

disease

Information about elderly patients?

Information about multiple comorbidity?

Information about elderly with multiple comorbidity?

diabetes mellitus Yes Yes Yes hypertension Yes No No osteoartrhitis Yes Yes Yes osteoporosis No No No

COPD No No No atrial fibrilation Yes Yes Yes

congestive heart failure Yes Yes No angina Yes Yes Yes

hypercholesterolemia Yes Yes No

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  hypothetic patient. 79 years, hypertension, COPD, type 2 diabetes, osteoporosis and osteoarthritis (all moderate)

Boyd CM, et al. JAMA. 2005; 294:716-24

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Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52

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  terminal patients: symptoms and personal care (no pain, no anxiety, no dyspnea, personal hygiene), preparation for death, stay mentally alert

  elderly: willingness to take preventive medications is very unsensitive to benefits but high sensitive to adverse effects

  reducing drugs do not solve all problems and concerns of the elderly ...

Steinhauser KE. JAMA. 2000; 284:2476-82. Fried TR. Arch Intern Med. 2011;171(10):923-8. Moen J. Patient Educ Couns. 2009;74:135-41

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poda

  given a particular patient, reconsider the therapeutic regimen, deprescribing the unnecessary drugs

more individualizing

time consuming

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  do the benefits outweigh the risks?

  exceeds the life expectancy of this patient the drug time to benefit?

  is it a logical piece in the current treatment regimen? Compare the indications for the drug and the goals of this patient care

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Garfinkel D, Mangin D. Arch Intern Med.

2010;170:1648-54

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tala

  given a particular inappropriate drug, review every patient that uses it and act

more feasible

less flexible

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  two kind of patients: terminally ill and fragile elderly

  more accepted and usual in terminally ill

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  outside agent: greater objetivity, worse actual knowledge about patient´s environment

  bedside health proffesional: greater acceptance (trust, longitudinal attention, accessibility)

Moen J. Patient Educ Couns. 2009;74:135-41

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  drugs reduction (mean 0.5-2.8/patient)

  hospital referals, less than control group (12% Vs 30%)

  mortality, less than control group (21% Vs 45%)

  no effect on quality of life and mental status

  no relevant adverse effects

  lower costs: 0,46 $ person/day

  limitations: small trials, no good randomization, no blind evaluation, selection bias…

Garfinkel D, et al. Isr Med Assoc J. 2007;9:430-4. Garfinkel D, Mangin D. Arch Intern Med. 2010;170:1648-54. Beer C, et al. Ther Adv Drug Safe. 2011;2:37-43

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Hardy JE, Hilmer SH. J Pharm Pract Res. 2011;41:146-51

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In the end I didn't know what was worse, um, having the … withdrawal effects from it or having the, um … depression side of it

I don't think I take them to sustain my mood but purely just to stop the side effects. I'll maybe be just have to grin and bear it

Leydon GM, et al. Fam Pract. 2007;24:570-5

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  tapper or discontinue gradually

  better in those with few drugs for a specific process

  close follow up at the beggining

  “opened door”

  shared decisions

  flexibility: any change is irreversible Leydon GM. Fam Pract. 2007;24:570-5

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health system   e-prescribing

  aggresive guidelines

  induced prescribing

physician barriers   prescribing, associated to every clinical encounter

  overmedicalization and overtherapeutic inertia

  we are not programmed to desprescribing

  lack of skills to change patient´s attitudes

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physician-patient relationship

  not addressing deprescribing with patient / family

  not considering patient´s perpective

patient

 “the time is over” / feeling of surrender

  fears, unpleasant past experiences

Leydon GM. Fam Pract. 2007;24:570-5. Hardy JE. J Pharm Pract Res. 2011;41:146-51

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  ageism

  paternalism or assymetry in decision making (i decide, then i inform you)

  forgetting the non-pharmacological aspects (psychological, social and family context, health system performance, expectations, clinical relationship ...)

Barsky AJ. Arch Intern Med. 1983;143:1544-8

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  firstly, non-pharmacological approach

  seeking the causes of the causes (fundamental causes)

  wait and see

  a few drugs, but well used

  the newest is not always the best

  changes, one by one

  adverse effects, on the jagged edge

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  anticipate possible adverse effects

  unbiased sources of information and learning

  enhance adherence

  patient-centered clinical outcomes rather than surrogate or intermediate markers

  remove the needless drugs

  promote conservative desires and healthy skepticism in patients Schiff GD, et al. Principles of conservative prescribing. Arch Inter Med. 2011

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It is an art of no little importance to administer medicines properly: but, it is an

art of much greater and more difficult acquisition to know when to suspend or

altogether to omit them Philippe Pinel. A treatise on insanity.1806

Antonio Villafaina Rafa Bravo Sergio Minué Beatriz González Marc Jamoulle … and all of you