James B. Ray, PharmD, CPEThe James A. Otterbeck Professor of Hospice & Palliative Care

University of Iowa College of Pharmacyjames-ray@uiowa.edu

11/18/2015

Deprescribing at the End-of-Life: Less is More

• Deprescribing – systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits in the context of an individual patients’ care

Brief background - definitions and statistics

• Packet of patient cases• Task– Identify which medications you would

deprescribe– Share rationale– Prioritize….which would you DC first?

CASES –

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• Clinical judgement and patient guided decision making– Ongoing discussion

• Standards of care and practice guidelines can be momentarily forgotten

Goals of Care

• Hyperlipidemia increases with age

• However, very old, severely ill patients, and actively dying patients may having declining LDL and TC levels

• Too low of TC may be a marker of poor outcomes

• Time-to-benefit for statins – 2-6 years

• Burdens of statins:– Myopathy and myalgias– Fatigue– Pill burden– Lab testing– Cost

Statins

http://www.cliparthut.com/sleeping-with-woman-at-desk-clipart.html

• Proven benefit for fracture prevention in osteoporosis and for women on anti-estrogen therapies

• Correct duration of therapy is unknown• Risks of bisphosphonates include:

• Short term» Headache, dyspepsia, abdominal pain, gastrointestinal ulcers, muscle cramps

• Long term» Bone fractures, chronic bone/joint/muscle pain, osteonecrosis of the jaw,

severe hypocalcemia

• Issues at the end-of-life– Administration– Cost – Adverse effects– Quality of life – Extended efficacy?

Bisphosphonates

http://www.myfamilymeddocs.com/service/osteoporosis/

• Primary prevention of cardiovascular disease and kidney disease• BP is used as a surrogate marker for control • Guideline driven care with specific BP targets – often >1 drug

• Issues at the end-of-life • Fatigue• Hypotension• Orthostasis• Falls• Cognitive impairment

Anti-hypertensives

Evidence-based recommendations: How do I stop it?

The how?

• If used daily for more than 3-4 weeks then:

• Reduce dose by 25% every week (i.e. week 1-75%, week 2-50%, week 3-25%)

• If intolerable withdrawal symptoms occur (usually 1-3 days after a dose change), go back to the previously tolerated dose until symptoms resolve and plan for a more gradual taper with the patient

• Dose reduction may need to slow down as one gets to smaller doses (i.e. 25% of the original dose)

• The rate of discontinuation needs to be controlled by the person taking the medication.

Benzodiazepines

• Symptoms to monitor for: – Rebound insomnia– Tremor– Anxiety – Hallucinations– Seizures– Delirium

Benzodiazepines

• If used daily for more than 3-4 weeks then:

• Reduce the dose by 25% every 3 to 4 days

• Once at 25% of the original dose and no withdrawal symptoms have been seen, stop the drug

• If any withdrawal symptoms occur, go back to approximately 75% of the previously tolerated dose.

Opioids

• Symptoms to monitor for:– Restlessness– Runny nose – Goose flesh– Sweating– Muscle cramps– Insomnia– Pain– Secretion of tears– Dilation of the pupils– Breathlessness– Decrease or impairment in daily function

Opioids

• If used daily for more than 3weeks: – Reduce dose by 50% every 1 to 2 weeks (7-10 days)– May stop once at 25% if not symptomatic– Metoprolol and atenolol

• Symptoms to monitor for:– Chest pain– Pounding heart– Blood pressure – does it need to be re-measured? – Anxiety– Tremor

Beta Blockers

http://thinkprogress.org/health/2013/01/31/1517821/fetal-heartbeat-bills-to-watch/

• If used for >1 week:– Reduce dose by 50% every week– May taper over 2-4 days – Oral versus patch?

• Symptoms to monitor for:– Rebound hypertension– Headache– Insomnia– Tachycardia– Hiccups– Salivation

Clonidine

http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=20848

• Depends on the agent! – Paroxetine and venlafaxine– Fluoxetine

• Taper over several months – reduce the dose by 25% every 4 to 6 weeks

• Symptoms to monitor for:– Insomnia– Flu-like symptoms – Imbalance– Sensory experiences (electric shock-like feelings)– Hyperarousal – N/V/D – Agitation

Anti-depressants

• Taper over 2-4 weeks

• Decrease dose by 25% every week

• Symptoms to monitor for:– High fever – Altered mental status– Muscle rigidity – Muscle cramps and pain

• Re-initiate therapy if symptoms are intolerable at 75% of the original dose

Baclofen

• Tizanidine• Corticosteroids• Anti-psychotics• Gabapentin• Anti-epileptics • Carisoprodol • Nitrates

Others

• Help patients understand WHY a medication may not be appropriate any longer

• Discuss how they may feel after stopping the medication

• Tell them HOW you are going to stop the medication

• WHAT are you going to do if symptoms come back?

• Use conversation to help understand your patient’s treatment target, goals of care, and overall wishes about medications

Be an advocate for your patients