Deprescribing: The Pill Dropouts

30. January 2018
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Every fifth patient is permanently taking three or more pharmaceutical products. Whether the medications cause harm in the long term is too often unquestioned by doctors for fear of rebound phenomena. Through the process of deprescribing, taking unnecessary pills is systematically eliminated for the benefit of the patient.

“I realised after only a few months that I can no longer sleep without medication”, says Karin V. *, 73 years old. “As soon as I have swallowed my pills, things get better”. Everything started with back pain. After her surgery, she received hypnotics and benzodiazepine but could not get herself off them. Dr. Rüdiger Holzbach describes the basic problem with the long-term intake of these drugs: “Actually, they do not help any longer, but taking them prevents withdrawal symptoms, so they keep on being taken”.

The doctor works as an expert on addictions in Augsburg (Germany) and knows the side effects: “We often see pseudodementia – patients have memory problems or concentration problems”. In addition, the risk of falling over increases. At the same time, “physical and emotional energy” drop. Benzodiazepines or z-drugs are however only part of the story. Medications such as proton pump inhibitors (PPI), statins or antihypertensives are often prescribed as part of long-term therapy, without their usefulness being checked.

Reducing step by step

So it is not surprising that according to data from ABDA (the Federal Association of German Pharmacist Associations eV) 23 percent of all adults in Germany take three or more medicines permanently. In 40 percent of all cases problems arise, for example through the interaction of pharmaceuticals. Doctors and pharmacists are not just trying to rectify these interactions. Their goal is also to reduce the intake of unnecessary or harmful medications. They are assisted by the procedure known as deprescribing, that is the systematic discontinuation of long-term medication. The most important questions here are:

  1. Which medications does the patient currently take?
  2. For what reason has a doctor prescribed the preparations? And does the requirement still exist?
  3. What risk comes with use of the medication? In addition to the actual active ingredient, pre-existing illnesses, age, gender and interactions come into play here.
  4. What is the benefit of the medication, should the therapy be continued?
  5. How can all the medications used by a patient be prioritised in terms of their benefit-to-harm ratio?
  6. Which medicines can be discontinued? And what are the undesirable effects to be expected in the first few days or weeks?

One outcome of deprescribing could look like this:

Deprescribing-1

© lessismoremedicine.com / Screenshot: DocCheck

Exact criteria or guidelines as to when to discontinue medications do not exist. This means that the doctor and the pharmacist need a lot of tact, as well as a lot of communication. That the procedure is justified is a matter beyond question. According to an older review article study, physicians and pharmacists have jointly managed to eliminate long-term pharmaceutical administration to at least 20 percent of all patients. Even with palliative patients this was possible on the basis of the scheme to reduce use of medications. There are now various studies on withdrawal options for particularly frequently prescribed drugs.

Stop acid blockers

Proton pump inhibitors have proven themselves in the treatment of acid-associated diseases like gastro-oesophageal reflux disease (GERD) . However, long-term therapies only make sense when specifically indicated for conditions such as for Barrett or Zollinger-Ellison syndrome. Their use is counter-weighed by their possible side effects, in particular suffering more fractures and getting infections more frequently. Nonetheless, physicians prescribe PPIs long term, without regularly questioning their usefulness. This is due to many doctors’ fear of rebound phenomena. This phenomenon in pharmacology denotes an overreaction accompanying the abrupt discontinuation of a drug. Such overly rapid discontinuation can lead to problems even in healthy people.

A few months ago, researchers at the Cochrane Collaboration investigated PPI exit strategies. Currently, however, too few methodically high-quality studies exist in order to be able to give a final recommendation. Canadian doctors have on the basis of further publications gone so far as to develop their own guideline on PPI describing. They advise adults who have been given acid blockers for at least four weeks due to heartburn, or mild to moderate gastroesophageal reflux disease or oesophagitis to follow the following procedure:

  • After consultation with the doctor or pharmacist, to reduce the dose (but not to cease taking medication abruptly),
  • Taking additional doses of their PPI when needed (“on demand”), should symptoms worsen.

Lifelong statins?

As with PPIs, statins are among the most commonly prescribed medications. Their use makes sense in patients as a primary and secondary prophylaxis against cardiovascular disease, yet they are used long term in association with type 2 diabetes and kidney damage. Doctors too rarely question whether such medication is still useful in the overall concept.

Do lifestyle interventions perhaps make the preparation superfluous? Or have liver and kidney function perhaps worsened, so that statins belong on the exclusion list? It’s frequently the case that preparations from this group of active agents are prescribed until the end of a patient’s life. In one large cohort involving more than 1,700 cancer patients, every third person was still receiving statins a month before his or her death.

The fact that deprescribing these medications is a risk-free option is demonstrated in a publication by Jean S. Kutner, researcher at the University of Colorado School of Medicine in Aurora. Together with colleagues, he enrolled 381 multimorbid patients in a study. 189 of them ceased statin therapy and 192 continued it. Kutner found no significant differences in their 60-day mortality. Cardiovascular events occurred in thirteen (deprescribing) versus eleven patients (long-term therapy). Doctors also cancelled prescriptions of other medications for those people who had dispensed with statins. Kutner suspected that these had mainly been prescribed so as to compensate for statin-associated side effects. On the whole, the quality of life without statin intake was significantly higher. Kutcher worked here using the McGill Quality of Life in Life Score. The questionnaire includes 18 questions about physical and psychological impairments due to having diseases.

Benzos remain problematic

Less promising are the deprescribing strategies employed with benzodiazepines and z-drugs. Emily Reeve from Sydney Medical School found seven studies in her literature research. Doctors invested their hopes in melatonin, and tried their luck with patient training or combined both methods. “Since the benefits and sustainability of these interventions are unclear, further studies should be undertaken to evaluate these”, Reeve says. Deprescribing therefore remains an important research topic.

* Name changed by the editor

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2 comments:

Dr. Fábián Ferenc PhD
Dr. Fábián Ferenc PhD

Day by day are coming patients to my pharmacy with long term medication problems, taking ten or more kinds of pills daily. Actually is very difficult to do anything.

Dr. Fábián Ferenc PhD
dreff47@gmail.com

#2 |
  1
Marsha Carter
Marsha Carter

Nice article! Glad someone is taking steps to stop the polymeds.

#1 |
  1


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