enrique gavilán
general practitioner

VI jornadas uso adecuado
medicamentos Plasencia 3 nov 2011

research department polypharmacy laboratory

www.polimedicado.com / enrique.gavilan@yahoo.es

  what   how

is “deprescribing”?

to deprescribe? the basis?

  what´re   how

to desprescribe? who? by whom? it works? the risk / barriers / threats?

  does

  what´re


+   discontinuation   drug removal / cessation   drugectomy   from polypharmacy to oligopharmacy

cut off





gotic deco



How? Fernandez did not come to work because he´s been buried? Well, I hope he do not forget to bring a certificate!

therapeutic retirement


diagnosing indicating prescribing supplying following up deprescribing
therapeutic chain




  process

of adaptation of drug regimen: tappering, replacing, eliminating drugs take in consideration the scientific evidence, social and physical function, comorbidity, quality of life and patient´s preferences

  must


1.  2.  3.  4.  5. 

review, review and again review reconsider therapeutic plan taper off, eliminate, substitute agree with the patient / caregiver follow up

Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51. Bain KT, et al. JAGS. 2008;56:1946-52. Woodward MC. J Pharm Pract Research. 2003;33:323-8.

  review   be

complete list of drugs

careful with over the counter drugs, naturopathics, non solid drugs reconciliation in medical

  medication

  poor

congruence with patient (58%)

Bikosky RM et al. JAGS. 2001;49:1353-7


Holmes H, et al. Arch Intern Med. 2006;166:605-9

  review

the indication (active?, goals?, time to benefit?) the compliance degree

  analize   detect   detect

adverse effects (present and risk)

drug-drug and drug-disease interactions

Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51

  no

longer used drugs for inactive or cured diseases that caused adverse effects

  drugs   those  

those that pottentially would cause relevant harms drug waterfalls

  vicious

Woodward MC. J Pharm Pract Research. 2003;33:323-8

  Beers

criteria 0,25 mg/d, in heart failure

-  digoxin, -  amitriptiline -  long

–anticholinergic and sedative propertieslife benzodiazepines –fall risk and sedationFick DM, et al. Arch Intern Med. 2003;163:2716-24



-  thiazides -  NSAID

if history of gout

if uncontrolled HBP, renal failure or gastric bleeding antimuscarinics if history of dementia or glaucoma
Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46:72-83

-  bladder


Maddison AR, et al. Prog Palliat Care. 2011;19:15-21

  explaining   talking,

and involving

informing, and, above all, expectations, beliefs

  preferences,   adapt

rythm to real posibilities

  enhancing

therapeutic adherence achievements

  highlighting   supporting   detecting

recurrence or worsening



  inappropriate

polypharmacy as a public health problem of scientific evidence for certain drugs

  absence

  ethics

criteria preferences

  patient´s

  40%

of institutionalized & 25% of outpatient elderly has at least one inappropriate drug >70 years use 5 or more drugs

  20%

  difficult

adherence, adverse effects, interactions, falls, morbidity, hospital admissions…
Wilcox SM, et al. JAMA. 1994;272:292-6. Rollason V, Vot N. Drugs Aging. 2003;20:817-32


Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31


N = 339. Age > 80 y Jyrkkä et al. Drugs Aging. 2009; 26:1039-48


are there evidences?

what tells the studies? and the guidelines ?

are there elderly in clinical studies?


Lee PY, et al. JAMA. 2001;286:708-13

patients included in clinical trials %
30 20 10

general population with dementia








age (years)
Schoenmaker N, Van Gool WA. Lancet Neurol. 2004;3:627-30



RR = 0.82 (0.69-0.99) NNT = 46 (637- 24)

HYVET Study. Beckett NS, et al. NEJM. 2008;358:1887-98


•  dependence personal hygiene: 1 point •  dependence in dressing: 1-3 points •  malignant disease: 2 points •  congestive heart failure: 3 points •  COPD: 1 point •  renal failure: 3 points

Carey EC, et al. JAGS. 2008; 56:68–75

•  congestive heart failure requiring treatment with a diuretic or ACO inhibitors •  renal failure (serum creatinine > 150 µmol/l) •  condition expected to severely limit survival, e.g. terminal illness •  clinical diagnosis of dementia •  resident in a nursing home (dependence) •  unable to stand up or walk … clinicaltrials.gov/


Van Bemmel T, et al. J Hypertens. 2006;24:287-92


Iyer S, et al. Drugs Aging. 2008;25:1021-31


Walma EP, et al. BMJ 1997;315:464–8


N = 5804, 70-82 y Shepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7

The fallacy of cheating death has been promulgated by the apostles of altered life-stile. In their enthusiasm, they have failed to stress that escaping death from myocardial infarction allows the possibility of dying from cancer, stroke or Alzheimer Disease
Mc Cormick JS, Skrabanek P. Lancet. 1984;2:1455-6


Hello, guy! How well you've come!


  if

it occurs in young patients: fast death, without suffering   in the elderly: a natural dying, “a good way of dying"

Emslie C, et al. Coronary Health Care. 2001;5:25-32 Mangin D, et al. BMJ. 2007;335:285-7

•  ibandronate, etidronate
no studies in this age group

only one trial that includes >80 y women: RRR non vertebral fractures 46% (not as end point) (Pols 1999)

•  risedronate
-  secondary prevention: RRR in morphologic vertebral fractures 81%, no effect on non-vertebral (Boonen 2004) - low risk primary prevent.: no effect hip fracture (McClung 2001)

•  zoledronate
- secondary prevention, 55% >75 y: RRR any new fracture 5%, no effect on hip fracture (Lyles 2007) - primary prevention, 37% > 75 y: RRR morphologic vertebral fractures 70%, 41% on hip fracture (Black 2007) Inderjeeth CA. Bone. 2009;44:744-51. Parikh S. J Am Geriatr Soc. 2009;57:327–34. Chua WM. Ther Adv Chonic Dis. 20011;2:279-86


RR = 0.6 (0.4–0.9), p = 0.009

RR = 0.8 (0.6–1.2), p = 0.35

McClung MR, et al. NEJM 2001;344:333–40


application of NOF guidelines to general population estimated that at least 34% of US white men aged 65 years and older and 49% of those aged 75 years and older would be recommended for drug treatment
Donaldson MG, et al. J Bone Mineral Res. 2010;25:1506–11


Black DM, et al. JAMA. 2006;296:2927-38


Lai SW, et al. Medicine. 2010;89:295-99

Information about elderly with multiple comorbidity? Yes No Yes No No Yes No Yes No


Information Information about elderly about multiple patients? comorbidity? diabetes mellitus hypertension osteoartrhitis osteoporosis COPD atrial fibrilation Yes Yes Yes No No Yes Yes Yes Yes Yes No Yes No No Yes Yes Yes Yes

congestive heart failure angina hypercholesterolemia

Boyd CM, et al. JAMA. 2005; 294:716-24


hypothetic patient. 79 years, hypertension, COPD, type 2 diabetes, osteoporosis and osteoarthritis (all moderate)

Boyd CM, et al. JAMA. 2005; 294:716-24


Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52


terminal patients: symptoms and personal care (no pain, no anxiety, no dyspnea, personal hygiene), preparation for death, stay mentally alert   elderly: willingness to take preventive medications is very unsensitive to benefits but high sensitive to adverse effects
   

reducing drugs do not solve all problems and concerns of the elderly ...

Steinhauser KE. JAMA. 2000; 284:2476-82. Fried TR. Arch Intern Med. 2011;171(10):923-8. Moen J. Patient Educ Couns. 2009;74:135-41


  given

a particular patient, reconsider the therapeutic regimen, deprescribing the unnecessary drugs

more individualizing
time consuming

  do

the benefits outweigh the risks?

  exceeds

the life expectancy of this patient the drug time to benefit? it a logical piece in the current treatment regimen? Compare the indications for the drug and the goals of this patient care

  is


Garfinkel D, Mangin D. Arch Intern Med. 2010;170:1648-54

  given

a particular inappropriate drug, review every patient that uses it and act

more feasible
less flexible



  two

kind of patients: terminally ill and fragile elderly accepted and usual in terminally ill

  more


  outside

agent: greater objetivity, worse actual knowledge about patient´s environment health proffesional: greater acceptance (trust, longitudinal attention, accessibility)
Moen J. Patient Educ Couns. 2009;74:135-41

  bedside


     

drugs reduction (mean 0.5-2.8/patient) hospital referals, less than control group (12% Vs 30%) mortality, less than control group (21% Vs 45%) no effect on quality of life and mental status no relevant adverse effects
lower costs: 0,46 $ person/day

     

limitations: small trials, no good randomization, no
blind evaluation, selection bias…

Garfinkel D, et al. Isr Med Assoc J. 2007;9:430-4. Garfinkel D, Mangin D. Arch Intern Med. 2010;170:1648-54. Beer C, et al. Ther Adv Drug Safe. 2011;2:37-43



Hardy JE, Hilmer SH. J Pharm Pract Res. 2011;41:146-51

In the end I didn't know what was worse, um, having the … withdrawal effects from it or having the, um … depression side of it I don't think I take them to sustain my mood but purely just to stop the side effects. I'll maybe be just have to grin and bear it
Leydon GM, et al. Fam Pract. 2007;24:570-5

  tapper   better   close

or discontinue gradually

in those with few drugs for a specific process follow up at the beggining door” any change is irreversible decisions
Leydon GM. Fam Pract. 2007;24:570-5

  “opened   shared

  flexibility:


health system
     

e-prescribing aggresive guidelines induced prescribing

physician barriers
       

prescribing, associated to every clinical encounter overmedicalization and overtherapeutic inertia we are not programmed to desprescribing lack of skills to change patient´s attitudes

physician-patient relationship
   

not addressing deprescribing with patient / family not considering patient´s perpective

  “the  

time is over” / feeling of surrender

fears, unpleasant past experiences

Leydon GM. Fam Pract. 2007;24:570-5. Hardy JE. J Pharm Pract Res. 2011;41:146-51


  ageism   paternalism   forgetting

or assymetry in decision making (i decide, then i inform you) the non-pharmacological aspects (psychological, social and family context, health system performance, expectations, clinical relationship ...)
Barsky AJ. Arch Intern Med. 1983;143:1544-8


   

firstly, non-pharmacological approach

seeking the causes of the causes (fundamental causes)
         

wait and see a few drugs, but well used the newest is not always the best changes, one by one adverse effects, on the jagged edge

       

anticipate possible adverse effects unbiased sources of information and learning enhance adherence

patient-centered clinical outcomes rather than surrogate or intermediate markers
   

remove the needless drugs

promote conservative desires and healthy skepticism in patients
Schiff GD, et al. Principles of conservative prescribing. Arch Inter Med. 2011

It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them Philippe Pinel. A treatise on insanity.1806 +
Antonio Villafaina Rafa Bravo Sergio Minué Beatriz González Marc Jamoulle … and all of you

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