By Miriam Sheinbein, M.D., HPSM Medical Director
In the June and October issues of HEALTHmattersMD, we offered simple tips that providers can use to improve patients’ medication adherence through:
- Asking patients about medication adherence,
- Following the 90x4 rule,
- Medication reconciliation and
- Simplifying medication regimens (i.e., combination medications).
This third article in our medication adherence series highlights another key way to simplify a patient’s medication regimen: deprescribing.
Too many medications?
The more medications that a person is prescribed, the more likely they are to be non-adherent with their medication regimen. That’s because polypharmacy (the regular use of five or more medications) increases both pill burden and the risk of adverse medication reactions.
Multiple medications may be indicated for patients with multiple chronic conditions, but we must remember that an essential part of good prescribing is deprescribing.
Deprescribing decisions
Guidelines for managing chronic conditions most often focus on which medications to initiate. However, to optimize clinical outcomes, we must also identify and prioritize medications that may be inappropriate, unnecessary, or harmful. As part of ongoing treatment, we must adjust medications to their minimum effective dosage or discontinue them altogether.
Deprescribe a medication when:
- It is no longer clinically indicated or medically effective.
- The potential for or evidence of harm from continued use outweighs the benefits.
Start the conversation!
Your patients rely on you to start deprescribing conversations. Doing so facilitates shared decision-making so you can work with patients to understand how reducing or stopping mediations can improve their quality of life while maximizing the benefits of medications in areas important to the patient.
- Start by choosing one to two patients per day with whom to initiate a deprescribing conversation.
- To encourage patient buy-in, consider discontinuing one medication at a time or tapering medications.
- When refilling medications, consider the benefits and risks of continuation for the short and long term. For automated refill requests, ensure the requested medication is part of the patient’s current regimen and that you are not refilling a discontinued medication.
- Be a judicious prescriber: before starting a new medication (especially for patients already on five or more medications), consider goals of therapy, risks versus benefits and alternative therapies.
Five steps for deprescribing
- Review indications for each medication and whether it is still meeting the patient’s medical needs.
- Determine eligibility for deprescribing: whether dosage can be reduced or the medication discontinued. This includes but is not limited to:
- Medications that are potentially inappropriate or the patient would like to consider stopping: evaluate for present or future adverse medication reactions (e.g., medication-medication, medication-food, medication-disease interactions or contraindications). Ask yourself and your patient whether their problem could be caused or exacerbated by a prescribed medication. See the resources below for tools that identify medications with higher risk profiles (e.g., benzodiazepines, anti-cholinergics).
- Medications that lack therapeutic efficacy: medications prescribed for a certain indication, without notable improvement (i.e., for management of anxiety or depression, hypertension, or type 2 diabetes).
- Medications that lack a particular indication: rule out “legacy prescribing” – that is when medications are initially prescribed for an intermediate duration, but continued indefinitely (e.g., PPIs, bowel regimens, anti-coagulants).
- Duplication of therapy and whether it provides additional benefit.
- Medications that take a long time to benefit patients and/or are unlikely to provide additional benefit during a patient’s lifespan (e.g., statins, aspirin).
- Complex medication regimen(s): evaluate for ways to optimize dosing regimens (i.e., change from BID to daily dosing; ensure appropriate renal and hepatic dosing adjustments).
- Develop a deprescribing plan with the patient through shared decision-making (i.e., weigh benefits and risks, consider costs, review goals).
- Create a follow-up plan: confirm which medications to stop or taper with the patient, review return precautions, and support the patient by monitoring for discontinuation (withdrawal) symptoms and/or establishing criteria for restarting.
- Remove discontinued medications from the patient’s active medication list.
Resources
(Note that no one tool has been shown superior in improving patient-related outcomes or decreasing polypharmacy risk.)
- American Geriatrics Society Beers Criteria (for potentially inappropriate medication use in older adults)
- Anticholinergic Burden Scales
- Deprescribing.org
- Epocrates
- Medication Appropriate Index Calculator
- MedStopper
- STOPP/START criteria