Deprescribing: Right-Sizing Medication Regimens to Optimize Outcomes in Palliative Care

Deprescribing in cardiometabolic conditions in older patients: a systematic review

We conduct a systematic review to investigate current deprescribing practices and evaluate outcomes and adverse events with deprescribing of preventive medications in older patients with either an end-of-life designation or residing in long-term care facilities with cardiometabolic conditions. Studies were identified using a literature search of MEDLINE, EMBASE, Web of Science, clinicaltrials.gov.uk, CINAHLS, and the Cochrane Register from inception to March 2022. Studies reviewed included observational studies and randomised control trials (RCTs). Data was extracted on baseline characteristics, deprescribing rates, adverse events and outcomes, and quality of life indicators, and was discussed using a narrative approach. Thirteen studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction or tapering, or switching to an alternative medication, for at least one preventive medication. Deprescribing success rates ranged from 27 to 94.7%. The studies reported no significant changes in laboratory values or adverse outcomes but did find mixed outcomes for hospitalisations and a slight increase in mortality rates when comparing the intervention and control groups. Lack of good-quality randomised control trials suggests that deprescribing in the older population residing in long-term care facilities with cardiometabolic conditions and multimorbidity is feasible when controlled and regularly monitored by an appropriate healthcare clinician, and that the benefits outweigh the potential harm in this cohort of patients. Due to the limited evidence and the heterogeneity of studies, a meta-analysis was not performed and as such further research is required to assess the benefits of deprescribing in this patient population. Systematic review registration: PROSPERO CRD42021291061.

Deprescribing, Polypharmacy and Prescribing Cascades in Older People with Type 2 Diabetes: A Focused Review

Deprescribing is the process by which medications are reduced without compromising safety to the patient (Jude et al. in 2022 Diabetes Ther 13: 619–634, 2022). The purpose of this narrative review is to discuss deprescribing as a topic, firstly discussing the benefits and pitfalls to such pharmacological interventions along with the current barriers and enablers to such a controversial topic, and then discussing deprescribing with respect to preventive medications, namely those that reduce the long term impacts of a condition or disease. Research that has previously focused on reducing polypharmacy has highlighted the benefits of such interventions, including reduction of adverse reactions or complications, improved patient satisfaction and quality of life, and improved cost effectiveness and drug compliance. Some potential harms that have been highlighted include an increased number of complications, increased symptoms of previously dampened conditions, and negligible changes in patient satisfaction that have stressed the importance of this intervention being patient centred and individualized to each patient. The implementation of deprescribing processes could drastically change the way people think about deprescribing and could be extremely beneficial to older patients living with type 2 diabetes worldwide. Developments in preventive medication deprescribing could pave the way for this intervention to become more common place improving the quality of life in patient’s final years.

Deprescribing Interventions by Palliative Care Clinical Pharmacists Surrounding Goals of Care Discussions

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Involving older people in decisions about deprescribing in end of life care

It is essential for all healthcare practitioners, including nurses, to recognise and respond to people's wishes and preferences for end of life care as part of a person-centred approach. Older people approaching the end of life are significant consumers of prescribed medicines and are at increased risk of adverse drug events. As such, prescribers and other healthcare practitioners should offer older people the opportunity to be involved in decisions about their medicines. This article focuses on older people and deprescribing in the last year of life. It provides an overview of the personalised care agenda, explores the risks and benefits of medicines among older people with advanced illness, and describes some of the most widely used deprescribing tools. The article emphasises a person-centred approach to end of life care and makes suggestions for holding discussions about deprescribing with patients and their families and/or carers.

Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings

The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.

Time to Deprescribe: A Time-Centric Model for Deprescribing at End of Life

In end-of-life care, deprescribing practices may vary considerably from one practitioner to the next, although most published frameworks for evaluating medication appropriateness in advanced illness consider three key principles (1) patient and caregiver goals, (2) remaining life expectancy (LE), and (3) medication time to benefit (TTB). The objective of this article is to provide clinicians with a structured, consistent approach for deprescribing that does not replace clinical judgment or the preferences of patients and their families but enhances it through clinical data. The emphasis will be on the time component of published models, including how to estimate remaining LE and medication TTB. Through case examples of two new hospice admissions, LE and TTB will be estimated and applied to deprescribing decisions. This time-centric approach may satisfy the palliative and hospice clinicians' desire for clear clinical justification for medication discontinuation while at the same time providing a strategy for communicating deprescribing rationale to patients and families.

Hospital Readmissions in Hospice Patients: Evaluation of Medication-Related Causes for Readmission

CONTEXT

Hospital readmissions, frequent medication changes, and polypharmacy are common issues for hospice patients. It is important to consider if close monitoring of medications by pharmacists could help these patients avoid hospital readmissions.

OBJECTIVE

The objectives of this study were to determine the incidence and types of medication-related problems that contributed to hospital readmissions from hospice settings.

METHODS

A retrospective chart review was conducted from October 1, 2018 to January 31, 2020. Patients admitted from hospice settings (i.e. Home, ALF, LTCF) and who were seen by the palliative care teams at 9 Maryland and Washington DC MedStar hospitals were included. Demographic information was collected: age, gender, race, primary hospice diagnosis, prognosis determined by provider prior to hospice disposition, reason for readmission, and medication list at readmission. The primary outcomes were the incidence and types of medication-related problems. Secondary outcomes included patient characteristics associated with readmission, and classes/number of medications changed before readmission. Descriptive statistics were used to analyze data.

RESULTS

Seventy-five hospice patients were readmitted and seen by palliative care during the study period. Forty-three patients (57%) were found to have medication-related problems at readmission. The most common problem identified was needing additional drug therapy. Dose too low, dose too high, incorrect drugs, adverse drug reactions, and non-adherence were also identified. Additional reasons for readmission were: unanticipated new medical issue (n = 46, 61%) and uncontrolled symptoms (n = 34, 34%).

CONCLUSIONS

These findings suggest that deprescribing practices possibly contributeto readmissions from hospice settings.