DEPRESCRIBING: AN OVERVIEW

Introduction

Deprescribing is the process supervised by a healthcare professional that involves tapering, withdrawing, discontinuing or stopping medicines to reduce potentially problematic polypharmacy, adverse drug effects and inappropriate or ineffective medicine use. It should be undertaken in the context of reviews for appropriate polypharmacy in partnership with the patient and supervised by a healthcare professional (Scott et al., 2015; Ulley et al., 2019; Lee et al., 2021).

Literature Review

Category of Patients who may benefit from Deprescribing

Polypharmacy – patients who use five (5) or more medications are at strong risk for medication-related problems (Kua, Mak and Huey, 2019).

Multimorbidity – As the number of chronic conditions increases, the risk of drug-disease interactions also increases substantially   

Renal disease patients: Decreased renal function increases the risk for adverse drug events, especially if there is inappropriate medication dosing (Linsky, Simon and Bokhour, 2015).

Multiple prescribers and transitions of care: Miscommunication about medications occurs when a patient has multiple prescribers or transitions from one care setting to another (Alhawassi et al., 2019).

Poor adhering patients:  Non-adherence has many causes, including dissatisfaction with medications, difficulty with medication use, and real or perceived adverse effects and/or lack of benefit (Abubakar et al., 2021).

Limited life expectancy –For patients with limited life expectancy,  a shift in goals of care from prolonging life to improving the quality of life could lead to a need to deprescribe certain medications (Steinman et al., 2014).

Advanced age –Older adults are often at high risk of medication-related problems due to the increased incidence of polypharmacy, multimorbidity, transitions of care, changes in pharmacokinetics and pharmacodynamics, and other risk factors (Akande-Sholabi et al., 2020).

Categories and classes of Medications requiring Deprescribing

Benzodiazepines and benzodiazepine receptor agonists — Because both psychological and physiologic dependence can occur with these medications, closely engaging patients, and offering alternate nonpharmacologic or pharmacologic therapies is essential. Tapering is recommended.

Proton pump inhibitors (PPI) — Risks of use include increased risk of Clostridioides difficile, colitis, hip fractures, and impaired vitamin B12 absorption (Park et al., 2017; Martin et al., 2018; Shrestha et al.,2020).

 Antipsychotics for behavioural and psychological symptoms of dementia or for insomnia — Since antipsychotics confer an increased risk of mortality in older adults with dementia, trials of discontinuation are warranted for patients whose behavioural and psychological symptoms have stabilized or who did not improve on antipsychotic therapy

Glucose-lowering medications — Deprescribing glucose-lowering medications may be warranted in patients for whom potential risks are likely to exceed benefits such as in the use of insulins and sulfonylureas especially glyburide (Martin et al., 2018).  

Cholinesterase inhibitors— Decisions about deprescribing cholinesterase inhibitors and memantine can be very challenging due to uncertainty about whether these medications benefit any patient. (Toshato et al., 2014)

Antidepressants: Withdrawal symptoms from antidepressant discontinuation are common and include insomnia, increased anxiety, and flu-like symptoms (James et al., 2014).

Some de-prescribing criteria and guidelines

1. American Geriatrics Society Beers Criteria (AGS/Beers Criteria) -This is an explicit criterion that provides detailed deprescribing algorithm for specific medications used chronically in the Ederly.
2. Screening Tool for Older Person’s Prescriptions (STOPP) criteria and Screening Tool to Alert Right Treatment (START) criteria – Developed as an alternative to Beers criteria for use mainly by European nations.
3. Improved prescribing in the elderly tool (IPET)/Canadian Criteria – This is more like the Canadian version of the beers criteria.
4. Medication Appropriateness Index (MAI) – This is an implicit criterion. It provides guideline for the appropriate use of certain medications. (Tosato et al., 2014; Fadare et al., 2015; AGS/Beers, 2019; Fick et al, 2019).

The 5-Step Approach to Effective Deprescribing:

      Step 1: Comprehensive medication history: Ascertain all drugs and the indications for each drug; are they having problems with any of their medications, and how does medication use fit into the larger picture of their health status, goals, and preferences?

Step 2: Identify potentially inappropriate medications: Assess each drug regarding its current or future benefit potential compared with current or future harm potential.

 Step 3: Identification and prioritization of which drugs to deprescribe:  Identify drugs that have the highest likelihood to cause harm than benefits and those with the lowest likelihood of adverse withdrawal reactions

Step 4:  Plan and initiate withdrawal: This stage involves the implementation of the discontinuation regimen. Stopping one drug at a time is usually recommended to encourage patient willingness and enable appropriate monitoring. Tapering is usually considered.

Step 5: Monitoring, support and documentation: Document the plan for deprescribing and any outcomes. Ensure ongoing communication with the patient (and their caregivers or family) and relevant healthcare professionals (Reeve et al., 2014; Scott et al., 2015; Lee et al., 2021).

Benefits of Deprescribing

The major goal of deprescribing is to improve patient quality of life and overall health outcomes. Specific benefits include:

●Reduction in the burden of medication – Medication review and aggressive discontinuation can lead to a reduction in up to thirty-nine per cent of medications used, including reducing use of potentially inappropriate medications by up to 30 to 60 percent or more. (Park et al., 2017).   

●Reduction in the risk of falls – Many medications increase fall risk especially in older adults. Examples include benzodiazepines and benzodiazepine receptor agonists such as zolpidem and zopiclone, antidepressants, antipsychotics, and strongly anticholinergic medications (Shrestha et al.,2020). Deprescribing them could help lower risk of falls.

●To Improve and preserve cognitive function –Discontinuation of benzodiazepines has been shown to improve cognitive function in nursing home residents (James et al., 2014).

● Reduction in the risk of hospitalization and death – In vulnerable older adults residing in nursing homes, trials of interventions incorporating whole-regimen review and deprescribing reduced hospitalization by 36 percent and death by 26 to 38 percent (Lattanzio et al., 2012).  

Risks/harms of de-prescribing

They include:

• Adverse drug withdrawal syndrome- to reduce this requires tapering o medications
• Pharmacokinetic changes – May due to inhibition/induction of CYP450 enzyme system
• Pharmacodynamic changes – Changes in clinical effects of other co-administered drugs.
• Return of the medical condition – for example, increased blood pressure.

(Reeve et al., 2015; Campins et al., 2017; Bloomfield et al., 2020).

Role of Pharmacists:

Medication reviews: Pharmacists conducts medication reviews to assess the appropriateness, effectiveness, safety and compliance of medications for a given patient.

Patient Education and counselling:  The pharmacists can take up a leadership role in educating patients of the risks of continuous uses of certain medications intended for short periods such as the benzodiazepines.

Patient Monitoring and follow ups:

Discharge counselling on medications conducted by the hospital pharmacist has been shown to improve medication adherence.  The community pharmacist monitors for adverse effects and adherence to medication changes.

 Conclusion and future directives:

De-prescribing can be framed as a part of good clinical practice. Shared decision-making is critical for the success of de-prescribing. Regular patient review is required for successful de-prescribing.  Senior citizens and those with multi-morbidity may benefit more from de-prescribing. In Nigeria, our healthcare team should collaborate towards establishing the prevalence of PIMs and thus develop a de-prescribing framework for clinical practice in Nigeria.

REFERENCES

Abubakar, U., Tangiisuran, B., Kolo, M., Yamma, A.I., Hammad M.A and Sulaiman S.A.S. (2021) ‘Prevalence and predictors of potentially inappropriate medication use among ambulatory older adults in Northern Nigeria’, Journal of Drugs and Therapy Perspectives, 37(1), pp 94–99.

Alhawassi, T.M., Alatawi, W. and  Alwhaibi, M. (2019) ‘Prevalence of potentially inappropriate medications use among older adults and risk factors using the 2015 American Geriatrics Society Beers criteria’ BMC Geriatrics 19(1), p154.

Akande-Sholabi, W.,  Ajilore, O.C., Showande, S.J. and  Adebusoye, L.A. (2020) ‘Potential inappropriate prescribing among ambulatory elderly patients in a geriatric Centre in southwestern Nigeria: Beers criteria versus STOPP/START criteria’, Tropical Journal of Pharmaceutical Research,19(5), pp 1105-1111 DOI: 10.4314/tjpr.v19i5.29

American Geriatrics Society Beers Criteria® Update Expert Panel (AGS/Beers). (2019)    ‘American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal of American Geriatric Society,  67(4): 674-694.doi: 10.1111/jgs.15767.

Bloomfield, H.E., Greer, N., Linsky, A.M., Bolduc, J., Naidl, T., Vardeny,  O.,  MacDonald, R., McKenzie, L. and  Wilt,  T. J. (2020) ‘Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis’,  Journal of Gen Internal Medicine, 35(11), pp 3323-3332. DOI: 10.1007/s11606-020-06089-2

Campins, L., Serra-Prat, M., Gozalo, I.,  Lopez, D.,  Palomera, E., Agusti, C.  and Cabre, M. (2017)  ‘Randomized controlled trial of an intervention to improve drug appropriateness in community-dwelling polymedicated elderly people’, Journal of Family Practice, 34(1), pp 36–42. Doi.org/10.1093/fampra/cmw073

Duncan, P., Duerden, M. and Payne, R.A (2017) ‘Deprescribing: a primary care perspective’, European Journal of Hospital Pharmacy, 24(1): 37–42. Doi:10.1136/ejhpharm-2016-000967

Fadare, J.O., Desalu, O.O., Obimakinde, A.M., Adeoti, A.O., Agboola, S.M. and  Aina, F.O. (2015) ‘Prevalence of inappropriate medication prescription in the elderly in Nigeria: A comparison of Beers and STOPP criteria’, The  International Journal of Risk Safety in Medicine, 27(4), pp 177-89.  Doi: 10.3233/JRS-150660.

Fick, D.M., Semla, T.P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C.E., Pezzullo, L., Epplin, J.J., Flanagan, N. (2019) ‘Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal of American Geriatrics Society, 67(4), pp 674-694.  Doi: 10.1111/jgs.15767.

Garfinkel, D. (2018) ‘Poly-de-prescribing to treat polypharmacy’, Journal of Therapeutic Advances in Drug Safety, 9(1), pp 25–43. DOI: 10.1177/2042098617736192

Kua, C. H., Mak, V.S.L. and Huey, L. S.W. (2019) ‘Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis’, Journal of American Medical Directors Association, 20(3), pp 362-372. DOI: 10.1016/j.jamda.2018.10.026

Lattanzio,F., Landi, F., Bustacchini, S., Abbatecola, A. M., Corica, F., Pranno, L. and Corsonello, A. (2012) ‘Geriatric conditions and the   risk of adverse drug reactions in older adults: a review’, Drug Safety Journal, 35(1) pp 55–61. Doi:10.1007/BF03319103

Lee, J., Negm, A., Peters, R., Wong,  E. K. C. and  Holbrook, A. (2021) ‘Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis’,    British Medical Journal, 11(2), pp e035978.  DOI: 10.1136/bmjopen-2019-035978.

Martin, P., Tamblyn, R., Benedetti, A., Ahmed, S. and Cara, T. (2018)  ‘Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-prescribe Randomized Clinical Trial’, The Journal of the American Medical Association, 320(18), pp 1889-1898.  DOI: 10.1001/jama.2018.16131

Marvin, V., Ward, E., Poots A.L., Heard, K., Rajagopalan, A. and Jubraj, B. (2016) ‘Deprescribing medicines in the acute setting to reduce the risk of falls’, European Journal of Hospital Pharmacy, 24(1), pp10-15. http://dx.doi.org/10.1136/ejhpharm-2016-001003

Maust, D.T., Strominger, J., Kim, H.M.,  Langa, K.M., Bynum S.C. (2021) J.P.W., Chang,  C.,   Kales, H.C., Zivin,  K., Solway, E. and Marcus, ‘Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US’,  The Journal of the American Medical Association, 325(10), pp 952-961.  DOI: 10.1001/jama.2021.1195.

Page, R.L.,  Linnebur, S.A., Bryant, L.L.  and  Ruscin, J.M. (2010) ‘Inappropriate prescribing in the hospitalized elderly patient: defining the problem, evaluation tools, and possible solutions’,  Clinical Interventions in Aging, 7(5), pp 75-87.  Doi: 10.2147/cia.s9564.

Park, H.Y., Park, J.W., Song, H.J., Sohn, H. S. and   Kwon, J. (2017) ‘The association between polypharmacy and dementia: a nested case-control study based on a 12-year longitudinal cohort database in South Korea’,  PLoS One Journal, 12(1), p e0169463. Doi:10.1371/journal.pone.0169463.

Potter, K., Page, A., Clifford, R. and  Etherton-Beer, C. (2016) ‘Deprescribing: a guide for medication reviews’, Journal of  Pharmacy Practice and  Research,46(4), pp 358-367. Doi.org/10.1002/jppr.1298

Reeve, E., Shakib,S., Hendrix, I., Roberts, M.S., Wiese, M.D. (2014)  ‘Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process’, British Journal of Clinical Pharmacology, 78(4), pp 738-747https://doi.org/10.1111/bcp.12386

Reeve, E., Gnjidic D., Long J. and Hilmer, S. (2015) ‘A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice’. British Journal of Clinical Pharmacology, 80(6), pp 1254-68. DOI: 10.1111/bcp.12732.

Shah, B. M. and Hajjar, E. R. (2012) ‘Polypharmacy, adverse drug reactions, and geriatric syndromes’, Journal of Clinical Geriatric Medicine, 28, 173–186. Doi:10.1016/j.cger.2012.01.00

Saka, S. A., Oosthuizen, F. and  Nlooto, M. (2019) ‘Potential inappropriate prescribing and associated factors among older persons in Nigeria and South Africa’, International Journal of Clinical Pharmacy, 41(1), pp 207–214. Available at https://link.springer.com/article/10.1007/s11096-018-0770-1

Shrestha, S., Poudel, A., Steadman, K. and Nissen, L. (2020) ‘Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review’, British Journal of Clinical Pharmacology, 86(10), pp1931-1945.  Doi: 10.1111/bcp.14113.

Scott, I. A.,   Hilmer, S.N., Reeve, E., Potter, K., Couteur, D.L., Rigby, D.,    Gnjidic D., Mar, C.B.D., Roughead, E.E., Page, A., Jansen, J. and  Martin J.H. (2015) ‘Reducing inappropriate polypharmacy: the process of deprescribing’, The Journal of the American Medical Association, 175(5), pp 827-834. Doi:10.1001/jamainuternmed.2015.0324.

Simoes, P.A.S., Santiago,L.M., Maurício, K. and Simoes, J.A. (2019) ‘Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study’, Journal of Patient Preference Adherence,13(1): pp1569–1576. doi:10.2147/PPA.S219346

Steinman, M.A., Miao, Y., Boscardin,W.J.,  Komaiko, K.D.R., Schwartz, J.B. (2014) ‘Prescribing quality in older veterans: a multifocal approach’. Journal of General Internal Medicine, 29 (10), pp 1379-86.   Doi: 10.1007/s11606-014-2924-8

Tosato, M., Landi, F., Martone, A.M., Cherubini, A., Corsonello, A., Volpato, S., Bernabei, R., Onder, G. (2014) ‘Potentially inappropriate drug use among hospitalized older adults: Results from the CRIME study’, Age and Ageing Journal, 43(6), pp 767-73. Doi: 10.1093/ageing/afu029.

Ulley, J., Harrop, D., Ali, A., Alton., S. and    Davis, S. F. (2019) ‘Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review’, BMC Geriatrics, 19(1), p 15.  DOI: 10.1186/s12877-019-1031-4