learning to deprescribe drugs, english version
TRANSCRIPT
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enrique gavilán general practitioner
research department
polypharmacy laboratory
VI jornadas uso adecuado medicamentos
Plasencia 3 nov 2011
www.polimedicado.com / [email protected]
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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