A practical approach to stopping medications

May 7, 2020

Contributed by:

Dr. Frances Carr, MBChB, FRPCP (Internal medicine, Geriatrics) (Click for bio)

Case

Mr. Jones is 89 and presenting with a four-month history of increasing confusion and recurrent falls. His past medical history includes Alzheimer’s dementia, benign prostatic hypertrophy, atrial fibrillation, insomnia, hypertension, anxiety and depression. His current medications include amitriptyline 50 mg daily, lorazepam 1 mg daily, amlodipine 10 mg daily, zopiclone 15 mg daily, oxybutynin (ER) 5 mg three times a day, donepezil 5 mg daily and furosemide 40 mg daily.

Issue

Older adults are more likely to develop multiple medical problems and be prescribed medications. As the number of medical problems increase, so does the number of medications that are prescribed. Older adults are at a high risk of experiencing complications from their medications, which includes adverse drug effects (e.g., falls, delirium) and polypharmacy, which is discussed later on. Stopping i.e., deprescribing, medications which are unnecessary or potentially inappropriate due to their high rates of side effects can reduce these risks; however, how this should be done is unclear.

Background

Older adults (65 years or over) are more likely to develop multiple medical problems than their younger counterparts for many reasons and are more likely to be prescribed medications. The physiological changes that occur with aging result in older adults being more sensitive to medications and puts them at a higher risk of developing adverse drug effects.1

Older adults are more likely to experience polypharmacy, which has been defined as the ‘intake of more medications by a patient than is clinically justified’.2 A 2014 CIHI report identified that two out of three Canadians over the age of 65 were taking at least five different prescription medications, with one in four Canadians taking 10 or more prescription medications.3 Polypharmacy includes the prescription of potentially inappropriate medications (PIMs) (e.g., Gravol, due to its high anticholinergic burden), prescribing cascades (the use of medications to treat the side effects caused by another medication) or the over or under-treatment of medical problems. Avoiding polypharmacy in older adults is important, as it has been associated with an increased risk of medication errors4, adverse drug reactions5 (such as falls6 and drug-drug interactions), higher financial costs, patient non-adherence and increased health care utilization.7 However, the process of deprescribing can be challenging for many reasons, which include embedded medications beliefs, time restrictions and lack of clarity around the deprescribing process. Another important barrier is lack of clarity around how to deprescribe, which is discussed below.

Evidence

Given the poor outcomes associated with polypharmacy, there is a growing need to address this problem. The deprescription of medications has been shown to provide financial benefits,8 and is likely safe.9 Stopping medications may also reduce the use of PIMs,10, 11 and can improve patient adherence.12 However, as mentioned earlier, the process of deprescribing can be challenging, which likely limits deprescribing efforts.

There is currently no standardized strategy for deprescribing medications. Deprescribing research has studied the impact from a variety of interventions which have included patient focused interventions,13 physician directed interventions,14 multidisciplinary team-based interventions,15 decisional based support systems,16 physician, health care team and patient education, pharmacist medication reviews and geriatrician involvement.17 The most successful interventions were those focused towards patients and those involving family physicians or the multidisciplinary team. Educating physicians alone was found to be ineffective.

Several organizations have developed deprescribing strategies targeted toward specific drugs/classes of drugs, with the most recognized being the Canadian Deprescribing Network18 and the Open Pharmacy Evidence Network,19 who together developed deprescribing algorithms for five groups of medications (protein pump inhibitors, anti hyperglycemics, antipsychotics, benzodiazepines/Z drugs, and cholinesterase inhibitors/memantine). While there is no recognized universal method for deprescribing, Frank and Welr20 developed a flow diagram detailing a general approach for describing.

There are also a number of tools available to assist with the deprescribing process, which includes Beers criteria,21 Medstopper,22 and the STOP/START tools.23-25 The Beers criteria helps with identification of PIMs, whilst the STOPP/START tools addresses under and over prescribing. Medstopper is an online tool that guides prescribers in recognizing PIM for deprescribing whilst also offering guidance around how to deprescribe.

In the absence of a standardized strategy for deprescribing, there are some key steps that should be incorporated into any deprescribing effort. These include performing a complete medication review, including both over-the-counter and complementary medicines. During this medication review, the Beers Criteria or Medstopper could be used to identify PIM, and the STOPP/START tools for under and over prescribing. An informed discussion should always be held between the patient and prescriber to establish deprescribing goals, which allows the development of an appropriate deprescribing strategy. During the deprescribing process, regular follow-up with the patient should be organized, which includes monitoring for withdrawal effects or emergence of the underlying disease.

Back to case

After doing a medication review, Mr. Jones was identified as being on two PIM’s (the amitriptyline and the Ativan), which had been prescribed for his anxiety and depression. After a discussion about more suitable and clinically appropriate medications, the decision was made to slowly taper down the amitriptyline over eight weeks, decreasing 10 mg every two weeks, with citalopram started at the same time. After the amitriptyline had been discontinued, the Ativan was then slowly tapered down over eight weeks by decreasing the dose by 0.25 mg every two weeks. A prescribing cascade was also identified as the furosemide was being used to treat leg edema caused by the amlodipine. Consequently the amlodipine was stopped and changed to Ramipril and the furosemide was stopped.

Recommendation

Older adults are more likely to be on multiple medications and developing medication-related complications. Deprescribing, where necessary, can reduce these risks and should include performing a medication review with the goal being to identify PIM or unnecessary medications. The deprescribing process will depend on the patient and medications involved, but should involve regular follow-up. This article provides prescribers a practical approach on how to identify and discontinue medications.

References

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