March 2017
clinical initiatives, research and current updates in treatment
Deprescribing Elke Fisher, Epic Pharmacy Greenslopes Two thirds of all Australians aged 75 and over and half of those aged between 65 and 74 take 5 or more medications every day.1 Whilst these medications may be considered necessary, taking multiple medications does not come without risk. 1 in 3 people, taking 5 or more medications, experience an adverse drug reaction (ADR) annually. More than one quarter of these ADR’s are considered preventable.2 The number of prescribed medications is emerging as the single most important predictor in the risk of ADR’s in older patients.3 The risk of an older person having an ADR is estimated to increase from 10% to 75% as the number of medications taken concurrently increases from 1 to 5 or more.4 More specifically, the risk of an older person having an ADR-related hospitalisation increases by 24% with each additional drug.4 One study focused on community dwelling older Australian men found taking 4.5 medicines concurrently was associated with an increase in falls and mortality, 5.5 medicines with disability and 6.5 medicines with increased frailty.5 Deprescribing has been defined as “the systematic process of identifying and discontinuing potentially inappropriate drugs with the aim of minimising
polypharmacy and improving patient outcomes”.6 Numerous events, such as increased frequency of falls, delirium, cognitive impairment, terminal illness and extreme frailty can all be triggers to deprescribing. Any older patients presenting with a new symptom or suspected of having an ADR, should be considered a candidate for deprescribing. Deprescribing is an essential component of the appropriate prescribing continuum, involving medicine initiation, review, dose titration, cessation or a complete medication change. It is not denying patients’ access to appropriate medications.3 Evidence based deprescribing involves systematically reviewing all medications, determining if a medication is considered of high or low utility, identifying and documenting any medications without a current indication and assessing the likelihood of misuse, toxicity or nonadherence, all within the context of each individual patient. Only one agent is to be ceased or reduced at a time. The “CEASE” deprescribing framework is explained in table 1.3 Providing an explanation to the patient of the rationale for deprescribing (i.e. reducing unnecessary medications that have
Table 1. CEASE deprescribing framework3
C E A S E
Current medications Elevated risk
Identify all of the patient’s current medications and their indication.
Assess
Determine the risk benefit ratio for each medication.
Sort
Identify possible medications for discontinuation, prioritizing those which are easy to discontinue and considered to be of minimal benefit. Patient preferences also need to be considered.
Eliminate
Implement a discontinuation plan and monitor patients closely.
Ascertain the risk of the patient experiencing an ADR, taking into consideration factors such as age, total number of medications, the presence of any high risk medications and specific patient characteristics.
minimal benefit or the potential to cause harm) increases the chance of success and empowers the patient to take better control of both their health and medications.6 Qi et al found if the doctor recommended stopping one or more of their medications, 89% of patients would be willing to trial it.7 Despite finding most patients are in favour of deprescribing, the following barriers may be encountered:6 ¬¬ Prior negative experience with drug withdrawal (e.g. rebound insomnia after ceasing a benzodiazepine) ¬¬ Anxiety and fear associated with the consequences of stopping a long term medication ¬¬ Reluctance to stop or reduce a medication the patient believes may prolong life or be of benefit ¬¬ A perception the patient is no longer worth treating i.e. the prescriber has given up A pilot study investigating deprescribing in 50 older patients (mean age 82.5 years) found it was possible to cease 186 of 542 regular medications (34.3%). 94% of participants had their medication load reduced by at least 1 and 50% by 4 or more.8 The most common discontinued medications were:8 ¬¬ Nitrates [8/11 (73%)] ¬¬ Inhaled bronchodilators [14/20 (70%)] ¬¬ Oral hypoglycaemics [9/15 (60%)] ¬¬ Antihypertensives other than ACE Inhibitors/Angiotensin Receptor Blockers [10/17 (59%)] ¬¬ Statins [21/37 (57%)] ¬¬ Benzodiazepines [8/15 (53%)] Continued on page 4