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Deprescribing in Palliative Care. Thursday September 26 th 2019 Beaumont Hospital Joanna Carroll, Senior Pharmacist. Outline. Polypharmacy Deprescribing Guidelines Examples. What is Polypharmacy?. Why is polypharmacy a concern?. Tilda: The Irish Longidudinal Study of Aeging.
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Deprescribing in Palliative Care Thursday September 26th 2019 Beaumont Hospital Joanna Carroll, Senior Pharmacist
Outline Polypharmacy Deprescribing Guidelines Examples
Tilda: The Irish Longidudinal Study of Aeging • Over one quarter of the older population (27%) are taking 5 or more medications (polypharmacy) and this had not changed since 2012 (2016 report) • While polypharmacy is linked to more falls and higher levels of adverse drug events and interactions, it may still be clinically necessary for an individual’s treatment regime. • Recommendations include regular medication review for those taking five or more medications
Prescribing Cascade Elderly patient established on amlodipine (blood pressure) ↓ Develops ankle oedema (side effect of amlodipine) ↓ Prescribed furosemide Prescribing cascade: When a new medicines is prescribed to ‘treat’ an adverse drug reaction associated with another medicine, in the mistaken belief that a new medical condition requiring treatment is present.
Deprescribing “Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit. Deprescribing is part of good prescribing – backing off when doses are too high, or stopping medications that are no longer needed.” www.deprescribing.org A new word for an old practice
Deprescribing The term ‘deprescribing’ has been suggested in recognition that the skills utilised in stopping medicines need to be as sophisticated as those used when initiating drug treatment. Key to deprescribing, as with all medical interventions, is the active participation of the patient to ensure that their preferences and choices are taken into account. Particular care is needed when end-of-life considerations apply, so that treatment is optimised and the burden of taking medicines is minimised
NHS Scotland 7 Step Medication Review • AIM: What matters to the patient/family? What symptom is most troublesome e.g. Parkinsons • NEED: Essential medicines e.g. replacement thyroxine, e.g. levodopa preventing rapid decline • NEED: Does the patient take unnecessary therapy? Temporary indications, higher than normal maintenance dose, limited benefit in the patient with limited life expectancy • EFFECTIVENESS: Are therapeutic objectives being achieved? Symptom control, prevent disease progression/exaccerbation Preventative medicines: Long time strategies need a long time
NHS Scotland 7 Step Medication Review SAFETY: Does the patient have or is at risk of an adverse effect? COST-EFFECTIVENESS: Is drug therapy cost-effective? Explore opportunities for cost saving if nothing else affected PATIENT CENTREDNESS: Is the patient willing and able to take drug therapy as intended? E.g. inhalers, eye drops
STOPPFrail -Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy Lavan A et al. Age and Aeging 2017
Barriers to deprescribing ‘Swimming against the tide’ of patient expectations Swimming against the tide: Primary Care Physicians Views on Deprescribing in Everyday Practice. Wallis et al. Ann Fam Med 2017.
Barriers to deprescribing Swimming against the tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice. Ann Fam Med 2017
Diuretics for swollen ankles **When there is no cardiac, hepatic or renal failure**
Proton Pump Inhibitors (PPIs) E.g Omeprazole, lansoprazole, pantoprazole, esomeprazole Indications: Gastric ulcers, reflux etc. Certain indications, PPIs SHOULD be continued Why consider deprescribing? www.deprescribing.org
PPIs e.g. Glioblastoma Multiforme (Grade IV Brain tumour) Median survival 14 months On regular steroids (dexamethasone 4mg QDS) Potential adverse effect GI bleed, gastric ulceration Good indication for PPI e.g. Stage III CHF (diuretic, ACI inhibitor, beta blocker) No GI history, no medicines that may cause GI upset ? No indication for PPI.
PPI “In our view, the recently published randomized trial provides considerable reassurance that PPIs are relatively safe drugs. Clinicians should reassure patients with legitimate indications for PPIs that the benefits are likely to outweigh the mostly unsubstantiated claims of serious adverse effects. If there are as-yet unidentified side effects of PPIs, the risks are very low. PPIs are an important cornerstone in managing gastroesophageal reflux disease, in treating patients with gastroduodenal ulceration, and in reducing the probability of upper gastrointestinal bleeding from aspirin or NSAIDs in high-risk patients. Of course, inappropriate use of PPIs should be avoided, as there is no threshold of acceptable risk for a drug that is not indicated.” Unravelling the safety profile of Proton Pump Inhibitors. NEJM JW Gastro August 2019. Saltzman et al.
