Deprescribing Goals in Polypharmacy

00:00 Hopefully, I've sold you on the value of a de-prescribing tool, like the STOPP, the MAT, or the START.

00:08 Because I wanna talk to you about how do you actually do that in your practice? How do you apply a de-prescribing strategy with your patients? The overarching goals for Deprescribing can kind of fall into four categories.

00:21 First one, reduce medication burden.

00:24 This improves medication compliance and it reduces the cost to the patients.

00:28 Second, preserve and improve cognitive function.

00:31 Number three, reduce the risk of falls, and number four, reduce the risk of morbidity and mortality, including hospitalization.

00:41 I want to walk you through a framework for your approach to Deprescribing.

00:46 Now there's going to be six parts to this.

00:48 Number one, thoroughly review each medication, including other OTC drugs and supplements. Number two, you need to create a clear picture of the patient, including psychosocial support systems and their ability to self-administer their meds safely.

01:04 Number three, review the goals for safe treatment.

01:07 Use one of the many online resources for checking possible drug to drug interactions.

01:12 This website that we're sharing with you is a comprehensive, professional and open access database. Now, it's specific to drug to drug interactions.

01:21 It provides abundant annotations for each DDI association, including the mechanism, description, risk levels, management strategies, alternative medications, etc.

01:32 All this in an effort to improve your clinical decision making and patient safety.

01:37 Number four, you need to thoroughly review each medication, including these things.

01:42 Look at the dose.

01:43 Are they on the lowest possible dose that's still therapeutic? Frequency? Are they on the simplest possible frequency? As you're reviewing the patient's complete med list, you may or may not know the indication for each medication.

01:58 Think about the efficacy of each medication.

02:01 Don't forget the adverse effects.

02:03 You want to replace the riskiest drugs first and barriers to compliance.

02:07 Again, keep it simple as much as you can for the client.

02:12 Number five, create a clear picture of the patient, including their risk for adverse effects, their cognitive function, and their physical health.

02:20 For example, renal and hepatic function and frailty.

02:24 Number six, review the goals of treatment in collaboration with your patient.

02:30 Now, here's some examples.

02:31 Will a statin provide a cardiovascular benefit in a patient with stage four lung cancer? Does an 86 year old need strict blood pressure and A1c goals? Now, treatment preferences may change.

02:44 You might focus on a symptom versus disease management, are there any medications the patient is highly motivated to discontinue? That's a great place to start.

02:54 In your own practice, these are things that you're going to want to think through so you can identify medication candidates that should be removed.

03:02 First, no valid indication for the medication.

03:06 For example, it could be a carryover medication from a recent hospitalization.

03:10 Next, ask yourself, is this indication still current? Is the indication no longer active, like they've completed PPI treatment for gastritis? That would be another reason to remove the medication.

03:23 Now, is this medication, remember you're going through them one by one, will this medication contribute to significant side effects? Is this medication started in relation to a prescribing cascade? Is this medication high risk for causing serious adverse events? Is the patient at high risk with this medication for drug to drug interactions? If there is a similar or same mechanism of action to another drug on the list, this is an excellent reason to consider removing that medication.

03:55 Does one med have a counterproductive mechanism of action to another drug on the list? Is the medication ineffective? Is it not being used? When you're considering the medications, preventative therapies in patients with limited life expectancy is something that you should consider, when you're removing or deprescribing medications.

04:17 The final one is the beer's criteria.

04:20 Now, this is available to you, it's open access, but this will help you understand specific drugs that are inappropriate for your patient.

04:29 Try to avoid automatic refills in new prescriptions Try to avoid automatic refills in new prescriptions and instead write a one month trial order instead.

04:37 So in conclusion, these are the things we want you to think about.

04:37 So, in conclusion, these are the things we want you to think about.

04:42 One, recognize when you're treating a patient who's in the highest risk for polypharmacy. Remember those groups? Anyone who has multiple medical conditions, they're managed by multiple subspecialist providers. Someone who has chronic mental health conditions, or someone who is residing in a long term care facility.

05:00 Remember, be on high alert for these vulnerable populations.

05:05 Number two, familiarize yourself with the medication review tools and how to use them.

05:11 Now, commit to making these interventions a priority in your practice by regularly reviewing the medication list, educating patients, and considering non-pharmacological alternatives.

05:23 I wanted to give you some examples of high risk medications.

05:27 You know, with diabetes medications, there's a risk of hypoglycemia.

05:31 Anticoagulants and antiplatelet medications, obviously, there's a risk of bleeding.

05:36 CNS depressants, there's a risk of confusion and falls.

05:40 Anticholinergic, there also is a risk of confusion and side effects like urinary retention, constipation, and dry mouth.

05:48 With diuretics, the client is at risk of dehydration and severe electrolyte derangements. Any medication with risk of renal dysfunction may reduce clearance and increase toxicity of other medications.

06:03 Once you've identified the medications that you plan to remove safely, I want you to think through these four steps.

06:10 First, it's ideal, that you plan to stop one drug at a time.

06:15 Now, the exception is if multiple are causing significant harm.

06:19 The reason for deprescribing one medication at a time is so that we have good understanding for what is causing any potential symptoms or effects that might develop. Number two, prioritize and decide in order for medication discontinuation.

06:34 Those that are causing the most risk or harm should go first.

06:38 Consider medications that the patient is most concerned about, also.

06:42 Number three, consider alternative options.

06:46 Treatments with potentially fewer side effects, like an SSRI instead of a TCA.

06:52 Think of increasing dosage of one medication to eliminate the need for another.

06:57 Combination pills.

06:58 Can you put lisinopril and hydrochlorothiazide together in a combination pill that makes the medication regimen simpler? There are also medications that can treat multiple indications, for example, bupropion can be for depression and smoking cessation.

07:14 Number four, it's critical that you identify situations where a taper is necessary versus an abrupt discontinuation.

07:22 You will want to avoid causing harm during tapering from withdrawal syndromes.

07:27 For example, tapering is involved in benzodiazepines, SSRIs, and opioids.

07:34 Guidance is limited.

07:35 Some start with 25 to 50% reduction every 2 to 4 weeks with very close monitoring, because you're going to want to go very slow, particularly with benzodiazepines.

07:46 Now adjust the plan if withdrawal symptoms do occur.

07:49 So, what is your role in monitoring? Safe tapering involves you being able to keep in close contact with the patient.

07:57 You're going to need to provide guidance on what symptoms the patient should look out for, and what monitoring is required.

08:03 Decide whether in-person, telehealth, or electronic messaging will be sufficient for monitoring progress.

08:09 Keep in mind, some attempts at Deprescribing may fail.

08:13 They may have recurrent or worsening symptoms.

08:16 Just stay flexible, it's all a process.

08:19 Document your plan clearly.

08:21 This is your chance to communicate.

08:23 You're able to communicate the issue and your reasoning to other clinicians, the patient, and yourself.

08:30 In regards to your documentation, I want to give you some very important strategies.

08:35 Now, first of all, you want to be purposeful and intentional.

08:38 And I know you're saying, um, of course I do.

08:41 And I know you're saying, of course I do.

08:41 But in this particular case, I want you to be thinking about medication management.

08:41 But in this particular case, I want you to be thinking about medication management.

08:47 There's a specific code for coding and billing that is medication management.

08:51 Now, that will be critical that you include that.

08:53 Now, that'll be critical that you include that.

08:54 But in order to use that code, But in order to use that code, you need to be very careful about documenting that you are discussing de-prescribing medications to reduce adverse effect risk, and that you're using one of these tools to do that.

09:08 Now, if you do these things, this is going to ensure that you are reimbursed for your time and your efforts.

09:15 I wanted to highlight five barriers to deprescribing that you may experience.

09:20 First of all, patient reluctance.

09:22 They may worry about feeling worse off medications or having symptoms return.

09:27 The second barrier is the clinician comfort level.

09:30 Medical inertia is a thing.

09:32 It's hard for clinicians to not treat some conditions.

09:36 We may also feel that reducing medications may cause harm.

09:40 And lastly, it's possible, particularly with psych meds, that prescribing provider may feel uncomfortable de-escalating psych therapy.

09:48 The third barrier is that you may have had limited clinical encounter time with the client. The fourth barrier is multiple consultants.

09:57 It is not unusual for a patient to be seeing multiple care providers.

10:02 So, think about communication.

10:04 Communication between health care professionals may be difficult or even nonexistent. Medications may be discontinued by one clinician and be inadvertently restarted by another clinician.

10:17 The prescribing provider may be worried about contradicting a consultant.

10:21 If the patient is seeing multiple prescribers, there is a risk that they could become confused from what they perceive to be mixed messages from all the consultants.

10:31 The fifth one involves the electronic health records.

10:34 If you remove a medication from your electronic health record, this may not communicate the change to the pharmacy.

10:40 So, previous prescriptions may remain active and get inadvertently refilled by the pharmacy. So, now you have your plan, you know how to identify medications that should be considered to be stopped or tapered, let's take a look at how polypharmacy happens. The patient is a 68 year old man.

10:56 They have a medical history of COPD and hypertension.

10:59 Now, in their social history this patient continues to smoke one pack per day.

11:04 The medications they're on are lisinopril, salmeterol, and albuterol.

11:10 His current medication list looks like this: lisinopril 20mg, salmeterol dry powder inhaler twice daily, albuterol inhaler as needed, and bupropion 150mg twice daily.

11:24 Unfortunately, this patient does not revisit his prescribing provider in the next year.

11:29 Let's say he moves to another state and establishes care with a new prescribing provider. Well, during this visit, he mentions symptoms of anxiety.

11:38 He does not disclose that he has been using his albuterol frequently.

11:41 He is prescribed sertraline for presumed GAD and alprazolam as needed.

11:48 The list on the left is his new medication.

11:51 The list on the right is what he's actually taking.

11:55 Now, when you look at those and you compare them, bupropion is something he's continuing to take, but that hasn't been prescribed by his new prescriber.

12:07 A month later, he's hospitalized on a ventilator for a COPD exacerbation.

12:12 Luckily, he improves and he's discharged with additional medications.

12:16 See the list there of his discharge medications.

12:21 Look specifically at the pantoprazole and the temazepam.

12:26 Now, after his hospitalization, his provider asked him to bring all of his medications for review. These are the medications he brought in to the provider.

12:35 So what do we do now? The patient's COPD exacerbation result and is COPD symptoms are better controlled.

12:43 However, he is not happy about the significant number of medications filling his med cabinet. The next step would be to identify medications without a solid indication. As you're looking through this list, look at the last two.

12:58 The pantoprazole and the temazepam.

13:01 These don't seem to have a solid indication.

13:04 The patient has been on bupropion for greater than a year at this point, and states that he hasn't had a cigaret in more than six months.

13:11 Bupropion, as it was indicated to stop smoking, is no longer necessary.

13:16 Assuming the patient's COPD is now better controlled and not requiring frequent Saba use, his anxiety symptoms are probably also improved.

13:25 For this case, let's say that is accurate, and he confirms that anxiety symptoms are not an issue, we can now highlight sertraline and alprazolam as unnecessary.

13:36 As we continue through this process in this case study, you see that now there are five medications that should be considered to be discontinued.

13:44 needed. Next, identify medications that were causing significant adverse effects.

13:49 The culprit here is the albuterol inhaler.

13:53 Identify medications that were prescribed in relation to another drugs side effects.

13:57 That would be the sertraline and the alprazolam.

14:01 Identify medications that could be high risk together.

14:04 Two serotonin acting agents and two benzodiazepines should catch your eye.

14:09 Take a look at the list which meds should be considered to be prescribed. It's safe to say that these are not only unnecessary at this point, but they would also make the list for deprescribing.

14:20 After coming up with a prioritization and deprescribing plan that the patient agrees to, you can also look at the medications that are left.

14:28 Now here, you'll know that he needs these treatments to control his COPD.

14:33 However, does he really need four separate inhaled devices? You can simplify this to make it easier on the patient.

14:41 This falls under the category of identifying medications for the same indication.

14:47 You take another look at the list.

14:49 We've grouped together the medications that are similar and we should consider another medication to meet those needs.

14:56 So the new medication list becomes: ipratropium-albuterol soft mist inhaler as needed, tiotropium-olodaterol soft mist inhaler daily, and lisinopril 20mg daily.