Imagine a scenario when a medication's long-term use is linked to serious adverse drug reactions or another case where there is no evidence of benefit if a medication is continued.
Surprisingly, when presented with these scenarios, prescribers may express reticence at stopping the medication citing the symptomatic benefit of the medications or concern for adverse clinical effects as a reason for continuing the medication.
Yet, many medications may not have benefits in the long term, especially for older patients, who are often excluded from clinical trials. For instance, older adults were excluded from randomized trials of bisphosphonate for osteoporosis, yet, research estimated that most nursing home residents with dementia who are prescribed bisphosphonates are at least 80 years old.
That’s where deprescribing comes in. Deprescribing is more than just stopping medication. In this article, we will discuss what deprescribing entails, the most efficient deprescribing strategies, and how healthcare teams can scale their deprescribing interventions.
In this article, we’ll discuss:
What is Deprescribing?
Inappropriate prescribing and polypharmacy, especially in older adults have been associated with an increased risk of negative health outcomes. Deprescribing has been identified as one approach to address some of the problems caused by polypharmacy.
A review published in the British Journal of Clinical Pharmacology defined deprescribing as “the process of withdrawal of an inappropriate medication, supervised by a healthcare professional with the goal of managing polypharmacy and improving outcomes”.
Because the process of stopping medications or dose reduction is complex and requires careful clinical consideration, the term “deprescribing” has been adopted, rather than just “stopping medication”.
Adverse Drug Interactions and Polypharmacy: Why is Deprescribing Important?
The rate of polypharmacy is rising. The Centers for Disease Control and Prevention estimated that 65% of older adults seen in physician offices experienced polypharmacy. In North America, more than 20% of typical outpatients from 40 to 79 years old, with chronic conditions experienced polypharmacy in 2015-2016.
Evidence has shown that the risk of drug-drug interactions increases with the number of medications taken, approaching 100% when 10 medications are taken concomitantly. The Low Institute estimated that polypharmacy will lead to over 4.6 million hospitalizations and 150,000 premature American deaths in the next decade.
Several risk factors, such as increased age and multimorbidity (the coexistence of multiple long-term conditions in one individual), can result in polypharmacy.
In addition, the number of treatment guidelines for long-term conditions has increased in recent years. Most guidelines specify how to start long-term treatment, but very few provide guidance on deprescribing.
Other factors that can increase the risk of polypharmacy are automatic refills, poorly updated medical records, and prescribing to meet disease-specific metrics.
Polypharmacy has been associated with elevated risk of adverse drug events, medication errors, poor adherence, and impaired quality of life. It’s especially a problem for vulnerable populations such as patients with chronic conditions or older adults. In addition to their physiological changes (which can increase their susceptibility to medication side effects), these populations often experience a decrease in cognitive and visual capacities, which can make managing a complex treatment regimen a great challenge.
Polypharmacy is a major public health problem and there’s an urgent need to address it.
Role of Deprescribing in Reducing the Risk of Polypharmacy and Drug Interactions
Benefits of Deprescribing Medications
Older people are specifically at high risk of experiencing adverse effects from medications. For this group, it is especially important to discontinue medicines that are no longer beneficial to avoid potential drug-related events.
Inappropriate polypharmacy is also expensive — researchers estimated it costs $177 billion to the U.S. each year — with its increased risk of adverse outcomes such as hospital admissions, falls, and premature mortality.
In older adults, deprescribing has been associated with decreased mortality, fewer referrals to nursing homes, reduced costs, and improvements in patients’ perception of their global health.
For instance, one study about deprescribing in residential care facilities found that deprescribing sedative and anticholinergic drugs significantly reduced the number of falls each person experienced.
A systematic review of deprescribing for older adults living in nursing homes, published in the Journal of the American Medical Directors Association found that deprescribing interventions in this population resulted in reduced all-cause mortality by 26% (OR 0.74, 95% CI 0.65-0.84), as well as the number of people falling by 24% (OR 0.76, 95% CI 0.62-0.93).
It is important to note that deprescribing in older adults is safe. A review published in the British Journal of Pharmacology found that in randomized studies of deprescribing interventions, there was no change in mortality (nonrandomized studies suggested that deprescribing reduces mortality).
Deprescribing Challenges
When asked about some of the barriers to deprescribing, healthcare providers often mention the lack of time and the concern, from both prescribers and patients, for negative health outcomes.
Some of the negative health outcomes that can potentially happen for older adults include:
- Adverse medication withdrawal events
- Return of health conditions
The potential negative outcomes can be minimized by slowly tapering off medications — besides benzodiazepines, anticonvulsants, and corticosteroids, most drugs can be safely tapered over four to six weeks if needed — and closely monitoring for withdrawal symptoms or signs of reappearance of the health condition.
If the health condition reappears, restarting the medication at a lower dose may be enough to manage it. In some cases, reappearance of the health condition may be temporary and just necessitate regular monitoring. For instance, a study about deprescribing antihypertensives in frail adults resulted in an immediate increase in blood pressure. However, the blood pressure reverted to baseline after nine months.
Lack of knowledge, different motivations of the prescriber and the patient, as well as poor communication, can also make deprescribing challenging.
Some of those challenges can be managed with the gradual introduction of the topic of deprescribing to the patient. It’s also important that patient, their caregivers, and prescribers establish shared decision-making and clear communication.
How to Determine When to Deprescribe
Target Populations for Deprescribing
Most of the research available is focused on deprescribing in older adults. Target populations for deprescribing include older adults on potentially inappropriate medications. Using specific criteria like the Beers lists or the STOPP criteria can help find those patients. Targeting patients on specific drug classes — such as benzodiazepine, opioids, or psychotropic medications — can also be effective.
Another population of patients that has been identified in research as a priority for deprescribing is nursing home patients. Indeed, two-thirds of nursing home patients take on average ten or more medications daily. And among residents with dementia, half receive at least one potentially inappropriate medication. For instance, these patients may be on cholinesterase inhibitors, e.g., donepezil and rivastigmine, for a long time, when this class of medications only has short-term benefits and a negative side effect profile.
Other populations that may be at risk for polypharmacy and benefit from deprescribing include:
- Younger adults with chronic pain
- Patients with mental health conditions
- Patients with multiple chronic conditions, e.g., diabetes, cancer, or heart disease
- Residents of long-term care facilities
- Patients without a primary care physician
Implementing Deprescribing in Clinical Settings
Deprescribing Strategies
Deprescribing can be implemented in different settings including nursing homes, primary care settings, and hospitals.
Deprescribing can also be implemented in community settings as shown by the EMPOWER trial published in JAMA Network. This study showed that direct-to-consumer education was an effective strategy to initiate deprescribing.
In patients who received deprescribing patient education materials explaining the risks of benzodiazepine use and a stepwise tapering protocol, 27% discontinued benzodiazepine use at 6 months. In the control group, only 5% of patients discontinued benzodiazepine use (risk difference, 23% [95% CI, 14%-32%]).
Some deprescribing interventions involve pharmacists reviewing the patient's medications using different deprescribing tools and making recommendations to physicians. In another intervention, the pharmacist had regular consultations with the patient and discussed the risks of falls, pain management, adherence, and general health.
One strategy included gradually discontinuing one target medication.
Yet another deprescribing intervention was part of a medication therapy management service. Educating providers was also used as a strategy for deprescribing.
Some of the tools that have been used to deprescribe are:
Multidisciplinary Approach
Several studies have shown the effectiveness of a multidisciplinary approach to deprescribing.
In one study about deprescribing sedative-hypnotic medications, published in the Journal of Primary Care and Community Health, the deprescribing team consisted of prescribers, clinical pharmacists, and behavioral health professionals. The intervention focused on educating primary care physicians (PCPs) as well as patients; and offered pharmacy-driven tapering plans, behavioral health services, or a combination of both to patients who opted in for deprescribing.
Researchers found that having PCP support was significantly more common in patients who discontinued their medications compared to those who did not (30% vs 7%, P = 0.003). Patients who received direct PCP support were almost six times more likely to discontinue medication use than those who did not receive PCP support (P = 0.006). This highlighted the importance of PCP support for successful deprescribing interventions. For patients with a history of falls, the number of falls was significantly lower in those who stopped the medication, compared to those who kept taking it (mean of 2.2 and 1.3 falls respectively, P=0.004).
In other deprescribing interventions, the multidisciplinary team consisted of nurses, geriatricians, a dietician, an occupational therapist, a physiotherapist, a speech therapist, a psychologist; or a geriatric consultant collaborating with a general practitioner.
In a review to identify what makes a multidisciplinary team work well for deprescribing interventions, researchers described the following elements:
- Clearly defined roles and good communication between the members of the team
- Integration of pharmacists into the team
- Team training
- Targeting high-risk patients
- Using deprescribing tools and drawing on the expertise of other HCPs, e.g., nurses and frailty practitioners
- Involving patients and caregivers in the deprescribing process
- Ensuring appropriate and tailored follow-up plans that allow continuity of care and management
Pharmacist-led Deprescribing
Deprescribing initiatives can also be led by pharmacists. Primary care physicians often cite lack of time and fragmentation of care as some of the barriers to deprescribing. Pharmacists often have access to a more complete list of the medications patients take. They may be in a more advantageous position to do thorough medication reviews, optimize medication regimens, and lead deprescribing interventions.
Pharmacists can implement deprescribing through relevant patient and prescriber education, doing comprehensive medication reviews and making recommendations, or fully managing medications through collaborative clinical practices.
One review of pharmacist interventions to deprescribe opioids and benzodiazepines found that the most effective deprescribing interventions seemed to be the ones using educational material and the ones where pharmacists engaged with patients and providers.
All interventions had specific criteria to target patients that may benefit the most from the interventions, e.g., patients taking benzodiazepines for more than three months, and patients on an opioid for at least 90 consecutive days.
In one of the landmark trials about deprescribing, the D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), community pharmacists engaged with both patients and their PCPs.
The pharmacists sent patients an educational deprescribing brochure, while their physicians received an evidence-based pharmaceutical opinion to recommend deprescribing.
After six months, 43% of patients in the deprescribing group had discontinued inappropriate medications compared to 12% in the control group (risk difference, 31% [95% CI, 23% to 38%]). The targeted medications were sedative-hypnotics, glyburide, and non-steroidal anti-inflammatory drugs.
In an evaluation of the economic impact of sedative deprescribing in the D-PRESCRIBE trial, researchers estimated that the pharmacist-led deprescribing may cost less (−CAD 1392.05) than the usual care, mainly thanks to the avoidance of falls, fractures, and other healthcare-associated expenses that can result from sedative use.
Future of Deprescribing
There has been a lot of interest and exciting research in the field of deprescribing since the term was first coined in an Australian pharmacy journal in 2003. Still, much more remains to be understood about deprescribing.
Although lots of research has been done, most of the outcomes have focused on rates of discontinuation and not on the impact of deprescribing on patient clinical outcomes.
Many deprescribing strategies focus on pharmacists or healthcare providers manually reviewing patients' medication regimens or sending individual education materials. In addition, patients are often targeted based on one or two criteria (usually a group of medications they take and their ages). These strategies may be effective for small groups of patients but may be challenging to scale.
To reach more patients and support more prescribers in their deprescribing initiatives, healthcare organizations need to utilize more scalable methods. AI-based technology platforms offer an important resource for more efficient deprescribing outreach strategies.
For instance, there may be a need to focus on higher-risk patients. Using predictive analytics can help deprescribing teams analyze broad population data sets so they can concentrate their resources on patients who may benefit the most from deprescribing interventions.
Arine’s artificial intelligence-powered platform enables health teams to identify high-risk patients using medical claims, pharmacy claims, and other health records, as well as behavioral and social data sets. The platform can also use this data to predict when care gaps are likely to occur so that care teams can intervene before patients experience negative consequences. In the case of deprescribing, this means that polypharmacy risks can be identified early and used to inform deprescribing strategies leveraging more comprehensive data sets to tailor interventions for each patient.
Similarly, instead of pharmacists reaching out to prescribers one by one, technology platforms can streamline the process and enable healthcare teams to engage promptly with a larger number of prescribers at once.
With its prescriber analytics solution, Arine enables clinical teams to uncover prescribing patterns across provider panels, identifying specific provider/patient opportunities for deprescribing and medication optimization. Its platform automates the generation of prioritized provider recommendations including patient-specific clinical context and guideline citations to support more effective communication with prescribers.
Using Arine’s medication intelligence platform, one of Arine’s health plan clients provided opioid medication management for 3.5 million of its members. Their clinical team used Arine’s platform to send targeted education and interventions to over five hundred prescribers. As a result, for members taking an opioid dose of more than 90 MME daily, >60% of members experienced a reduction in average daily MME.
Conclusion
The United States is suffering from a medication overload epidemic, touching mostly older adults and vulnerable populations. If this crisis remains unaddressed, we may witness thousands of avoidable and premature deaths in the next decade. Deprescribing provides one strategy to help address this polypharmacy crisis. Arine’s medication intelligence platform enables care teams to strengthen and expand their deprescribing capabilities at this critical time.
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