Monday, July 10, 2017

Polypharmacy and Deprescribing

A recent survey among older adults in 11 countries reported the highest rates of multiple conditions, such as hypertension, heart disease, diabetes, lung problems, mental health problems, cancer and/or joint pain and arthritis, in the United States (68%) and Canada (56%) compared with European countries and Australia. As a result, older adults are likely to be prescribed multiple medications (polypharmacy) and utilize more healthcare, at a higher cost, compared with patients with no or fewer chronic conditions.

Polypharmacy and potentially inappropriate medications in older individuals are associated with adverse drug events, death, impaired physical and cognitive function, falls, and hospitalization. Approximately 53% of over-65s in the United States and 42% in Canada take four or more prescription drugs. Many over-65s take five or more prescription drug, and this rate is increasing. Reports indicate that in Canada, seniors with three or more chronic conditions take an average of six prescription medication and more than 30% are believed to be taking at least one medication that is potentially inappropriate.

Dr. Barbara Farrell, assistant professor in the Department of Family Medicine, University of Ottawa, Canada, notes that at her hospital it is not unusual to see a patient on 25-30 medications. “Frequently, a medication is started to see whether it will help with certain symptoms –almost like a diagnostic test – but then the medication is never stopped,” she explains. “Ten years go by, and the family doctor retires or dies, and the patient sees a men family doctor who doesn’t know why the drug was prescribed in the first place but is scared to stop it. I see patients in the 80s and 90s who have been on a medication for 30 years, and no one can remember why they are taking it.”

Although the term “deprescribing” (defined as reviewing and identifying medications to be stopped, substituted, or reduced) first appeared in the literature in 2003, the problem of polypharmacy in the elderly has been recognized for 30 years. “People had been trying to raise the alarm all that time, but only in past 4-5 years have we seen greater awareness of the increasing cost to the system,” Dr. Farrell points out.

Current clinical practice guidelines do not typically take into consideration the long-term net benefits and harms associated with all medications that older patients with multiple chronic conditions would be taking if evidence-based guidelines for each condition were followed. “All the clinical guidelines tell you how to start drugs, but not how to stop them. So, we thought, why don’t we try to create a deprescribing guideline, following the same rigorous processes that you would use for an evidence-based prescribing guideline,” Dr. Farrell recalls.

The first four guidelines of “Deprescribing Guidelines for the Elderly” cover proton pump inhibitors, benzodiazepine receptor agonists, antipsychotics, and antihyperglycemics. A fifth guideline in preparation will cover acetylcholinesterase inhibitors in the treatment of dementia.

“Ideally, in the next 10 years, I would like to see all prescribing guidelines have deprescribing sections, so that people can see, in a patient with a certain condition not only when to start a drug gut also the reasons for decreasing the dose or stopping the drug later, and how to go about it,” says Dr. Farrell.

My Take:
This vital research is long overdue and unfortunately reflects the ongoing influence that Big Pharm has on our health care system. Polypharmacy now extends to our mid-aged and even young adults. It’s like driving a car that can go faster and faster, but has no brakes.

The Bottom Line:
Speak to your primary care physician about any medications you take. Lists of potentially inappropriate medications and tools for deprescribing include the Beers criteria, as recently updated by the American Geriatrics Society and STOPP (Screening Tool of Older Persons’ Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment).

Source: June 1, 2017 Medscape

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