1Deprescribing Definition
The systematic process of identifying and discontinuing drugs in instances in which existing or potential __________ outweigh existing or potential __________ within the context of an individual patient's care goals, current level of functioning, life expectancy, values, and preferences
- Harms
- Benefits
2Deprescribing
What are the steps to deprescribing?
1. Med history
2. Assess potential for deprescribing
3. Prioritize meds for D/C
4. Patient/provider discussion
5. Final deprescribing action
3Deprescribing
What is step 1?
Getting a good medication history
4Medication History
What are things to consider when gathering a med hx?
- Medication history (including indication): In hospital medications?
- OTC and supplements
- Prescriber history
- Pharmacy refill history
- Medication adherence
5Medication History
What is the overall goal?
To have an accurate, comprehensive med list
6Deprescribing
What is step 2?
Assess potential for deprescribing
7Assess Potential for Deprescribing
What are the 9 questions we should be asking about the med list?
1. Does each medicine have an indication?
2. Is the medicine appropriate for the indication?
3. Are there any contraindications present?
4. Has the indication resolved?
5. Is the patient still benefitting from this medicine?
6. Is the medicine potentially inappropriate?
7. Are there important interactions to consider?
8. Is the medicine appropriate for life expectancy?
9. Is the patient adherent to the medicine?
8Assess Potential for Deprescribing
What are 4 situations that present opportunities to stop a medication? Which is the best time to do this?
- Care transitions: Best time!
- Annual/semiannual medication review
- Review existing medications before starting a new one
- Presentation or identification of a new problem or complaint
9Assess Potential for Deprescribing
What are the two resources mentioned to help with assessing deprescribing?
Medstopper
Deprescribing.org
10Assess Potential for Deprescribing
How does Medstopper.com work?
Enter in the list of medications a patient is receiving
Medstopper sequences the drugs from "more likely to stop" to "less likely to stop", based on three key criteria:
- Potential of the drug to improve symptoms
- Potential to reduce the risk of future illness
- Likelihood of causing harm
Also has tapering recommendations
11Assess Potential for Deprescribing
Deprescribing.org aims to do what 3 things?
- Provide tools for patients and providers who are participating in deprescribing
- Share information about ongoing and completed deprescribing research
- Link people globally who are interested in deprescribing
12Assess Potential for Deprescribing
Deprescibing.org has guidelines and deprescribing algorithms for what 5 drug classes?
- Antihyperglycemics
- Antipsychotics
- Benzodiazepines and "Z-drugs"
- Cholinesterase inhibitors and memantine
- Proton pump inhibitors
13Deprescribing
After we have assessed for deprescribing, what is the next step?
Prioritize medications that need to be prescribed
14Deprescribing
What is a clinical set of symptoms or signs that are related to the removal of a drug?
Adverse drug withdrawal events (ADWE)
15Final Deprescribing Actions
What is the most important thing to do? Why?
Communicate clearly with patient, caregiver, and provider
- Plan must be clearly stated to patient (and caregivers) or they will come back and not have made any changes and you will have to start all over again!
16Final Deprescribing Actions
What are the other actions in addition to patient/caregiver education? (3)
- Document process and outcomes with rationale
- Cancel refills at the pharmacy
- Medication disposal / drug take back events
17What patients should we target who are good candidates for deprescribing?
- Limited life expectancy
- Cognitive impairment
- High medication burden
- High risk for ADR
- 8+ medications
- 75 and older
- Taking high-risk meds
18What should we consider when deprescribing ? (4)
- Risk versus benefits
- Focus of treatment
- Best medication
- Goals of care