June 16, 2021

How providers—and their patients—are reaping the benefits of ‘deprescribing’

Daily Briefing

    Many older adults are prescribed a potentially dangerous number of prescription drugs, a trend several recent initiatives are trying to combat through "deprescribing," in which providers and patients routinely review medication regimens to "prune away" risky or unneeded drugs, Paula Span writes for the New York Times.

    Background

    According to Span, as many as two-thirds of older adults are on at least five medications at a time, a situation called polypharmacy. More broadly, "polypharmacy refers to an increasing overload of drugs that may not benefit the patient or interact well with one another, and that may cause harm including falls, cognitive impairment, hospitalization, and death," Span writes. In fact, according to Span, adverse drug reactions account for about 1 in every 11 hospitalizations for older people.

    Often, this situation reflects a "fragmented health care system," Span writes, in which an older patient can receive certain medications from one specialist and others from another specialist, neither of whom are familiar with the other drugs the patient has been prescribed. Meanwhile, the patient's primary care physician may be reluctant to "overrule" the patients' specialists, Span writes.

    "We spend hundreds of millions every year to bring meds to market and figure out when to start using them, and next to nothing trying to figure out when to stop them," Caleb Alexander, an internist and epidemiologist at the Johns Hopkins University School of Medicine, said.

    How polypharmacy can harm patients

    For instance, one older patient, Mary Harrison, was taken for a medical assessment at Johns Hopkins Hospital in 2018, after her daughter, Leslie Hawkins, noticed that Harrison—usually a sociable, outgoing woman—"couldn't hold a conversation or even finish a sentence." At the hospital, Harrison was able to answer just 3 of 30 questions included on a common dementia test.

    But at Hawkins' prompting, Stephanie Nothelle, a geriatrician at Johns Hopkins, reviewed a list of the 14 medications Harrison was taking for conditions ranging from diabetes to hypertension—and several of the drugs "alarmed" Nothelle, Span writes. Nothelle recommended Harrison immediately stop taking two medications—a bladder-health drug called oxybutynin and the pain medication Tramadol, which can both contribute to delirium among older patients—and discussed a plan to prune more medications down the line.

    Advocacy groups try to make headway—but obstacles remain

    In response to situations such as Harrison's, several advocacy groups and initiatives have arisen to promote "deprescribing"—the act of pruning away unnecessary and potentially harmful drugs from patients' medication regimens, Span writes.

    For instance, the Society for Post-Acute and Long-Term Care Medicine just last month launched the Drive to Deprescribe campaign, calling for a 25% reduction in medication use at long-term care facilities within the year. So far, according to Span, 2,000 facilities have joined the campaign, as well as three major consulting pharmacies that work with those facilities. That total that is small compared to the nation's 15,000 nursing homes, but it’s a significant start.

    Similarly, the U.S. Deprescribing Research Network, which was established in 2019, has allocated nine grants aimed at testing effective deprescribing plans. According to Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the network, thoughtful deprescribing strategies are necessary because stopping a medication "is not just the reverse of starting one. It's often much harder." 

    Not only does deprescribing require some level of coordination between a patient's various specialists and general care givers, but it also goes against what Ariel Green, a geriatrician and researcher at Johns Hopkins, calls medicine's "general bias toward doing things." As Green explained, "If we prescribe something, that's seen as a positive action. If we stop something, or don't start it, that's not."

    In addition, while most older adults say they are willing to reduce the number of prescribed drugs they take, research also indicates that they tend to think all their medications are needed—and some older adults may interpret a deprescribing as a sign providers are withdrawing or denying them care, Green added.

    What deprescribing success looks like

    However, although research suggests that many deprescribing initiatives have "little impact," a recent clinical trial in Canada has shown significant promise, Span writes. In that trial, participating pharmacists gave patients a deprescribing brochure before refilling certain prescriptions. They also gave prescribing providers forms indicating potentially harmful drugs and enabling providers to switch or remove certain prescriptions by just checking a box.

    Within six months, Span writes, 43% of patients using sedative-hypnotic drugs were able to stop using them, as were 30% of patients using the diabetes drug glyburide and 57% of patients using NSAIDs. "It was spectacular," Cara Tannenbaum, a geriatrician at the University of Montreal and senior author of the study, said, adding that the next step is figuring out how to "scale it up and get it out of research projects and into everyday practice."

    Patients and their loved ones can also be proactive by routinely asking providers to review the medications they've been prescribed, such as through so-called "brown bag review," where patients bring all their pill bottles for review at once. And various groups, including the American Geriatrics Society, have published lists of potentially dangerous or unneeded medications.

    According to Span, such strategies can dramatically help patients. When Hawkins wasn't able to bring her mother back to Johns Hopkins right away for additional help with deprescribing, she began to ask providers at every interaction whether drugs were needed or could be reduced or stopped altogether.

    By the time Harrison returned to see Nothelle, 10 months after her first appointment, "she was a completely different person," Nothelle said, able to answer 25 of the 30 questions on the dementia assessment. And while Harrison still needs "considerable assistance," Span writes, she is down to just four medications—and is the "life of the party," according to Hawkins (Span, New York Times, 6/7).

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