Deprescribing Demystified - PowerPoint Presentation

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Deprescribing Demystified

Lynsey E. Brandt, MD, PharmDGeriatrics Consult ProgramSeptember 1, 2016Slide2

Geriatrics Consult Program

Lynsey Brandt, MD, PharmD

Located at Wilmington Hospital

Gateway Building, 5

th floorScheduling: 302-320-6475

FallsPolypharmacyMedical ComplexityWeight loss/ failure to thriveDelirium Depression/ AnxietyInsomnia, Urinary Incontinence, or FatigueNeed for Increased Social SupportDriving ConcernsGoals of CareSlide3

Deprescribing is…. Slide4

Deprescribing is….

A new way of thinking about medication use in older adultsA systematic approach to medication debridementA catchy new term that DAFP created to get people to come to this conference

1 & 2

1, 2, & 3Slide5

Deprescribing is….

A new way of thinking about medication use in older adultsA systematic approach to medication debridement

A catchy new term that DAFP created to get people to come to this conference

1 & 2

1, 2, & 3Slide6

(August 15, 2016)Slide7

“This

is America’s other drug problem — polypharmacy,” Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical

“There are a lot of souvenirs from being in the hospital: medicines they may not need,” said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

“There’s a

tendency in medicine every time we start a medicine to never stop it.” Ken Covinsky, UCSFSlide8

Learning Objectives

Understand

principles of safe medication use in older adults (renal dosing, drug interactions)

Identify

medications which are high-risk in older adults (Beers list, Anticholinergics, and selected other

examples)Review guidelines for deprescribing medicationsProvide deprescribing resources for providers and patientsSlide9

Case 1

Mr. JH is an 85 yo man who resides in an assisted living facility. PMH: Parkinson’s, Mild dementia (MMSE = 21), HTN, urinary incontinence, constipationBP range 80/40 to 150/80Walks with stooped posture, unsteady gait, needs assistance to transfer from chair to wheelchairSlide10

JH Medication ListSlide11

JH (Cont)

Pt and family asking whether all these meds are needed…“Hx of falls. Assist with meds.”“No prior hx of HTN - on metoprolol after one elevated BP reading. Dtr wonders if over-medicated

.”

“Dtr

asking why bladder med needed since he wears a brief”“Family also asking why needs water pill, as ankles have not been swollen.” Illustrates importance of having an advocateMore about JH later…Slide12

The Polypharmacy Problem

Community dwelling older adults: 90% >

1

med

40% > 5meds12% > 10meds

One third of hospitalizations in older adults are medication-related Gurwitz JH et al. JAMA. 2003;289(9): 1107-1116.Scott IA et al. JAMA Internal Medicine May 2015Slide13

Consequences of Polypharmacy

Increased healthcare costsAdverse drug events

Drug interactions

Medication Non-adherence

Decreased functional statusGeriatric Syndromes: Delirium, Falls, Urinary Incontinence

Maher RL, et al. Expert Opin Drug Saf. January 2014. Slide14

How can we address polypharmacy?

Utilizing age-appropriate prescribing principles Minimizing use of potentially inappropriate medicationsDeprescribing when possible Slide15

Principles of Medication Use in Older AdultsSlide16

Principles of Medication Use in Older Adults

Renal DosingDrug Interactions“Start Low and Go Slow”Beware of the Prescribing CascadePotentially Inappropriate MedicationsSlide17

Renal DosingRenal function declines with age

Renal mass declines by 20-25% from age 30 to 80Glomerular Filtration Rate decreases by 10% per decade of life after age 30Slide18

Renal Dosing

Do not be misled by “normal” serum creatinine.Adjust dose when creat clearance < 60

Calculate creatinine clearance using the Cockcroft-Gault equation:

(

140-age in years) x (Ideal body wt) x 0.85 (females)72 (serum creatinine in mg/ dL)Slide19

Renal Dosing

What is the GFR for: 90 year old woman, who weighs 90 pounds, and has serum creatinine of 1?Slide20

Renal Dosing

What is the GFR for: 90 year old woman, who weighs 90 pounds, and has serum creatinine of 1.0?Slide21

Drugs with renal elimination

(selected examples)

Allopurinol

Antibiotics

- Aminoglycosides

- Fluoroquinolones - Penicillins - Tetracyclines - Sulfa - NitrofurantoinDigoxin

Furosemide

Gabapentin

H

2

antagonists

- Cimetidine

- Famotidine

- Ranitidine

Lithium

MetforminSlide22

Drug InteractionsSlide23

Risk of Drug Interactions

Increased probability of drug-drug interactions in patients taking more medicationsStudy of hospitalized older adults taking 5 or more medsPrevalence of cytochrome p450 interaction = 80%Study of community-dwelling older adults

5 to 9 meds: 50% probability

20 or more meds: 100%

Maher RL, et al. Expert Opin Drug Saf. January 2014Slide24

Cytochrome P450 Systems

CYP3AMetabolizes >60% of prescribed drugs including:

Calcium channel blockers, certain beta-blockers, most “statins”, warfarin, amiodarone

CYP2D6Metabolizes: metoprolol, propranolol, tramadol, codeine,oxycodone,TCAs, SSRIsSlide25

Cytochrome P450 Inhibitors

CYP3A InhibitorsAmiodarone, cimetidine, cyclosporin, erythromycin, itra-/ketoconazole, grapefruit juice

CYP2D6 Inhibitors

Cimetidine, SSRIs, quinidineSlide26

My approach to Drug Interactions

Be aware of drugs frequently implicated WarfarinAmiodaroneCalcium channel blockersStatinsSSRI

QTc-prolonging agents (atypical antipsychotics, fluoroquinolones, citalopram)

Take the time to review the interactions in the EMR Slide27

Strategies to check for drug interactions

Micromedex/ LexicompEpocratesThe pharmacist!!Slide28

Potentially Inappropriate MedicationsSlide29

The Beers List

List of drugs which are potentially inappropriate in the elderlyDeveloped by consensus panel of geriatricians in 1991Used by regulators to evaluate nursing home medication listsUtilized by third party payors to evaluate medication listsSlide30

The Beers List (selected examples)

Drug

Reason

Alternative

Antihistamines- 1

st

generation (diphenhydramine)

Anticholinergic effects

Nonsedating antihistamines (loratadine)

Long-acting benzodiazepines (diazepam)

Sedation

Short-acting benzodiazepines (lorazepam)

Narcotics (meperidine)

Active metabolite

Morphine

Hypoglycemic agents (chlorpropamide)

Long half-life, renally excreted, risk of hypoglycemia

Shorter-acting agents (glipizide)Slide31

Other high-risk medications

Study of 177,504 ER visits for adverse drug events33% of the visits were due to:DigoxinWarfarinInsulin

(“DWI”)

Drugs on the Beers list accounted for only 3.6% of visits

Budnitz et al. Annals of Internal Medicine. December 4, 2007 vol. 147 no. 11 755-765 Slide32

Drugs with Anticholinergic Properties

Elavil (amitriptyline)

Flexeril

(cyclobenzaprine)

Cogentin (benztropine) Atarax/Vistaril(hydroxyzine) Bentyl (dicyclomine)

Levsin (hyoscyamine)Ditropan (oxybutynin) Antivert (meclizine)Detrol (tolterodine) Ipratropium (atrovent)Benadryl (diphenhydramine) Phenergan

(promethazine)

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Prescribing Cascade

Could this apply to pt JH?Slide34

DeprescribingSlide35

Case 2: LG

90 yr old woman PMH Hypertrophic cardiomyopathyOsteoporosisMemory lossReason for consultation: Weakness

Medications : Furosemide 20 mg 3x/

wk

, Calcium, Vit D, Alprazolam 0.25 mg daily at bedtimeSlide36

LG (cont.)

Pt reports that she has been taking alprazolam daily at bedtime since her husband passed away in 2007She has a history of 2 prior falls, which she attributes to trippingYou want to address the long-term benzodiazepine use, but have discussed this with her previously & she was not interested in stopping the medication. How to proceed?

What resources exist to help address this problem?Slide37

Deprescribing

Definition:The systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values, and preferences.

Scott IA et al. JAMA Internal Medicine May 2015Slide38

Definition (cont)

Patient-centeredInvolves inherent uncertaintiesRequires:Shared decision-making

Informed consent

Close monitoring of effects

Scott IA et al. JAMA Internal Medicine May 2015Slide39

Patient presents with new symptoms which could be adverse drug effect (i.e. falls, confusion, fatigue)End-stage disease/ terminal illness

Receiving high-risk drugs/ combinationsReceiving preventive drugs in scenarios where drug can be safely discontinued (i.e. d/c bisphosphonate after 5 years with no increase in osteoporotic fracture risk over the ensuing 5 years)

When to consider deprescribing?

Scott IA et al. JAMA Internal Medicine May 2015Slide40

Priority Drugs for Deprescribing

Aim to ID and prioritize med classes where evidence-based deprescribing guidelines would be of benefitSurvey of 65 Canadian geriatrics experts (36 pharmacists, 19 physicians, 10 CRNP)Modified Delphi approach5 priorities: benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors.

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Farrell B, et al. Plos ONE. Jan 1 2015. Vol 10 Issue 4.

reSlide41

Deprescribing ProtocolSlide42

5 Steps of Deprescribing*

1.) Ascertain all drugs the patient is currently taking and reasons for each one2.) Consider overall risk of drug-induced harm in individual patients to determine the appropriate intensity of deprescribing intervention

3.) Assess each drug in regard to its current or future benefit potential compared with current or future harm / burden potential

Scott IA et al. JAMA Internal Medicine May 2015Slide43

5 Steps (cont).*

4.) Prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes5.) Implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects.

*These steps can be applied to a patient of any age who takes multiple long-term medications

Scott IA et al. JAMA Internal Medicine May 2015Slide44

Current indications

Why/ when started?

Was diagnosis substantiated?

Prescribing cascade

Is there continued benefit?Are other nonpharmacologic therapies available?

Deprescribing Protocol (cont.)Slide45

Is patient actually taking the drug?

Does drug fit with patient’s life circumstances?

Advanced dementia

Metastatic cancer

Does likely benefit of drug outweigh potential for harm?

Consider “high-risk” drug classes: opioids, benzos, psychotropic drugs, NSAIDs, Anticoagulants, digoxin, cardiac drugs, hypoglycemic agents, anticholinergic drugs. Deprescribing Protocol (cont.)Slide46

Group drugs into 2 categories:

1.) Disease/ symptom control

2.) Preventive

Deprescribing Protocol (cont.)Slide47

Deprescribing: Evidence of Efficacy

Drug withdrawal trialsMultifaceted interventions aimed at reducing inappropriate prescribing across multiple drug classes and settings

Scott IA et al. JAMA Internal Medicine May 2015Slide48

Drug Withdrawal Trials

Systematic review of 31 withdrawal trials (15 RCT, 16 observational)Pts 65 and overMultiple drug categories: Antihypertensives,

psychotropics

, benzodiazepines

Dc’d without harm in 20 to 100% of patients *Reduction in falls and improvement in cognitive and psychomotor function (Psychotropics, Benzos)Also replicated in another review (van der

Cammen)Iyer at al. Drugs Aging, 2008:25(12)1021-1032. Slide49

Drug withdrawal trials (cont.)

Review of 9 randomized-trials Demonstrated safety of withdrawing antipsychotic agents Used for behavioral and psychologic symptoms of dementia80% of participants with dementia were able to safely stop antipsychotics

Declercq

T et al. Cochrane Database

Syst Rev. 2013. Slide50

Drug withdrawal trials (cont.)

Australian National Blood Pressure studyNot designed as deprescribing trialFound that 37% of participants remained normotensive 1 yr after drug withdrawal

Neson

MR, et al. BMJ. 2002.Slide51

Empower Study (Eliminating Medications Through Patient Ownership of End Results)

Test whether the direct-to-consumer educational brochure is effective at reducing benzos, compared to usual careCluster randomized trial

:

The

cluster is the community pharmacy from which patients are recruitedRandomized to brochure immediately or after a 6-month waiting period Inclusion criteria = benzo use for 3 months+, age

65+Tannenbaum et al. JAMA Internal Medicine 2014. Slide52

EMPOWER = “Eliminating medications through patient ownership of end results.”

ownership of end results”Slide53

EMPOWER Study Results

86% of participants completed 6-month follow-up62% or recipients in intervention group initiated conversation about benzodiazepine therapy cessation At 6 months, 27% of the intervention group had discontinued benzodiazepine vs 5% of control group (Risk difference of 23%, 95% CI 14-32%. )Slide54

EMPOWER Study Conclusions

Direct-to-consumer education effectively elicits shared decision-making related to overuse of medications that increase the risk of harm in older adults. How can we apply these results in practice?Deprescribing.orgSlide55
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Summary:Strategies for successful deprescribing

Empowered patientsQuery pts about adverse effectsPractical guidance on how to safely wean particular classes of drugsSlide61

Barriers to Deprescribing

Clinical complexity

Time constraints

Multiple prescribers

Incomplete informationAmbiguous / changing goals of care

Uncertainty about benefits/ harms or continuing or stopping certain meds“More is better” philosophySlide62

JH Medication ListSlide63

Case 1 (JH) follow-up

BP 100/60- reduced lasix to 3x/ wkReduced oxybutynin to 5 mg daily – no apparent chg in sxSlide64

Case 1 (JH) follow-upFollow-up visit:

BP- follow-up -now on lasix 3x/ wk. States had SBP 150 this AM.BP on my exam 80/40

DC’d lasix

Metoprolol may also be dc’d

No change in urinary symptoms on lower dose oxybutyninSlide65

Case 2 (LG) Follow-up

At time of last visit, LG was contemplating a change in her alprazolam usagePlan to implement Deprescribing.org resources…Slide66

Geriatrics Consult Program

Lynsey Brandt, MD, PharmD

Located at Wilmington Hospital

Gateway Building, 5

th floorScheduling:

302-320-6475FallsPolypharmacyMedical ComplexityWeight loss/ failure to thriveDelirium Depression/ AnxietyInsomnia, Urinary Incontinence, or FatigueNeed for Increased Social SupportDriving Concerns

Goals of CareSlide67

Questions?