Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper

Pharmacist-led deprescribing of cardiovascular and diabetes medication within a clinical medication review: the LeMON study (Less Medicines in Older Patients in the Netherlands), a cluster randomized controlled trial

BACKGROUND

Deprescribing inappropriate cardiovascular and antidiabetic medication has been shown to be feasible and safe. Healthcare providers often perceive the deprescribing of cardiovascular and antidiabetic medication as a challenge and therefore it is still not widely implemented in daily practice.

AIM

The aim was to assess whether training focused on conducting a deprescribing-oriented clinical medication review (CMR) results in a reduction of the inappropriate use of cardiovascular and antidiabetic medicines.

METHOD

A cluster randomized controlled trial involving 20 community pharmacists, who conducted a clinical medication review in 10 patients. The intervention group received training on deprescribing. Patients 70 years or older with polypharmacy having a systolic blood pressure below 140 mmHg and using antihypertensive medication and/or an HbA1c level below 54 mmol/mol and using antidiabetic medication, were included. Follow-up took place within 4 weeks (T1) and after 3 months (T2). The primary outcome measure was the proportion of patients with one or more cardiovascular and antidiabetic medicine deprescribed within 3 months after the CMR (T2).

RESULTS

A total of 71 patients in the intervention group and 69 patients in the control group were included. At T2, 32% of patients in the intervention group and 26% in the control group (OR 1.4, CI 0.65-2.82, p = 0.413) had one or more cardiovascular or antidiabetic medicines discontinued. Regarding any medication, these percentages were 51% and 36%, (OR 1.8, CI 0.92-3.56, p = 0.085) respectively.

CONCLUSION

Increased awareness and ability of community pharmacists to deprescribe medication and use of general practitioners' data, led community pharmacists and general practitioners to successfully conduct a more deprescribing-focused CMR in daily practice. Further research is needed to assess the necessity of additional training to optimize the deprescribing of cardiovascular and antidiabetic medication. The study was registered at The Netherlands Trial Register (registration no: NL8082).

Pharmacology; ii. Cardiovascular Disease and iii. Systematic Review and Meta-analysis. Effectiveness and safety of chronic diuretic use in older adults: an umbrella review of recently published systematic reviews and meta-analyses of randomized-controlled trials

BACKGROUND

Healthcare providers should balance the potential risks and benefits of chronic diuretic use, particularly in older adults, as with age, diuretic benefits may decline and risks increase. A comprehensive synthesis and critical evaluation of the available evidence on chronic diuretic treatment effects is currently lacking.

METHODS

We conducted an umbrella review of systematic reviews and meta-analyses published since 2018 on health outcomes associated with diuretic use in randomized-controlled trials (RCTs). We conducted random-effects meta-analysis for pooled effect estimates and narratively summarized data that could not be pooled.

RESULTS

We included 741 effect estimations from 117 systematic reviews (SRs) on 1566 RCTs in individuals aged 62 ± 6 years. Of our 33 meta-analyses, 11 provided convincing, high-quality evidence: finerenone reduced the risk of cardiovascular (CV) mortality and end-stage kidney disease in individuals with chronic kidney disease (CKD) and/or type 2 diabetes (T2D). Torasemide reduced the risk of heart failure-related hospitalization (HFH) more than furosemide in individuals with HF. Thiazides reduced CV events in individuals with hypertension. Mineralocorticoid receptor antagonists (MRAs) reduced HFH, but also increased hyperkalemia risk in individuals with HF. MRAs also reduced the risk of atrial fibrillation in those with HF or CVD, and reduced HFH, major adverse cardiovascular events (MACEs), > 40% eGFR decrease, and composite kidney outcomes in individuals with CKD and/or T2D. Lower quality evidence suggests that in older (≥ 65 years), but not in younger adults, diuretics may reduce CV mortality, but also increase adverse event (AE) risk.

CONCLUSIONS

Our umbrella review offers a comprehensive and up-to-date evaluation of the benefits and harms of diuretics. However, further research is needed to establish their efficacy and safety in populations commonly seen in clinical practice, especially older adults living with multimorbidity and frailty.

International Deprescribing Guidelines Did Not Impact Actual Practice in Deprescribing of Potentially Inappropriate Medications for Nursing Home Residents: An Interrupted Time Series Analysis

BACKGROUND

Deprescribing guidelines reduce the use of potentially inappropriate medications (PIMs) in trial settings; however, their real-world impact remains unclear. Therefore, this study assesses deprescribing trends and the impact of guideline publications (STOPPFrail, proton pump inhibitors [PPIs], and antipsychotics) on these trends among nursing home residents with limited life expectancy in Belgium.

METHODS

Deprescribing was assessed using linked healthcare reimbursement data for all residents aged 65 years and older who died between 2014 and 2019. In total, 15 PIMs from STOPPFrail version 1 were selected. Deprescribing was operationalized as discontinuing at least one PIM in the last 4 months of life among those who had been prescribed these medications chronically between 6-12 months prior to death. To identify changes in the trend of deprescribing, we employed a joinpoint linear regression model. We calculated the average quarterly percent change (AQPC) and 95% confidence intervals (CIs). In addition, we used autoregressive integrated moving average (ARIMA) modeling to explore the impact of publication of these guidelines on four commonly used PIMs: PPIs, antipsychotics, lipid modifying agents, and calcium.

RESULTS

Among 244,865 residents, 169,782 (69.3%) were chronically prescribed at least one PIM and 50,487 (29.7%) had at least one discontinued. The prevalence of deprescribing declined from 31.7 to 27.66% between the first quarter of 2014 and the fourth quarter of 2019, with an average quarterly percent change decline of - 0.47% (95% CI - 0.85, - 0.10). No joinpoints were identified, indicating a consistent linear trend with no interruptions or statistically significant shifts in the rate of change in deprescribing prevalence. ARIMA modeling found that the publication of deprescribing guidelines had no impact on deprescribing trends.

CONCLUSIONS

Despite the high use of PIMs, and the publication of the STOPPFrail, PPI, and antipsychotic deprescribing guidelines, deprescribing rates remained low and even decreased. These findings emphasize the importance of implementation efforts that go well beyond guideline publications to effectively change deprescribing practices.

Deprescribing for nursing home residents with limited life expectancy: A qualitative study to identify barriers and enablers for healthcare professionals

Nursing home residents with limited life expectancy often take many medications eligible to deprescribing. Deprescribing is crucial but not yet routinely implemented. Therefore the aim of this study was to explore healthcare professionals (HCPs) barriers to and enablers for deprescribing and to identify theoretical domains for behavior change to be included into future interventions. A qualitative descriptive study using semi-structured interviews was conducted among 28 HCPs working in Belgian nursing homes. The data were analysed inductively using thematic analysis followed by mapping barriers and enablers to theoretical domain framework (TDF), and linking the domains to behavioral change techniques (BCTs). We identified multifaceted barriers and enablers across six themes: healthcare system and policy factors, resource- and organization-level factors, professional role and competency factors, interprofessional collaboration and communication factors, attitudes and perceptions towards deprescribing, and triadic dynamics in deprescribing. These barriers and enablers were mapped to 13 of the 14 TDF domains.

Medication Management in Patients With Polypharmacy in Primary Care: A Scoping Review of Clinical Practice Guidelines

OBJECTIVE

Inappropriate polypharmacy increases the risk of medication-related issues. Adequate management of polypharmacy is a challenge involving different healthcare professionals, complex decision-making and ideally including patient involvement. The objective of this scoping review was to provide an overview of national recommendations for medication management of patients with polypharmacy in primary care.

METHODS

A scoping review of clinical practice guidelines focusing on medication management in adults with polypharmacy, applicable to primary care was performed. Databases (G-I-N, Turning Research into Practice and PubMed), network, and a global report were screened for guidelines published after 2000 in English, Dutch, German, Spanish, French, or Russian. Raw data were extracted in duplicate using an extraction framework focusing on strategies, involvement of professionals, patient involvement, and implementation. Qualitative content analysis was used. Guideline quality was assessed using AGREE-II. The study was registered with the Open Science Framework.

RESULTS

Eight guidelines originating from eight countries were included. The most common recommended strategy was a medication review conducted by a general practitioner and/or a community pharmacist. Tasks and target population differed per guideline. Most guidelines recommended involving the patient in the process, mostly to elicit the patient's experiences and treatment goals. Few guidelines included advice on the implementation of recommendations. Three out of eight guidelines were of good quality (AGREE-II score >70% in 5/6 domains).

CONCLUSIONS

Most guidelines recommended a medication review, with patient involvement, as a strategy for medication management in polypharmacy in primary care. Guidance on task division and implementation of guidelines in practice was less clear. This review illustrates room for guideline improvements.

Multicomponent intervention to tailor prescriptions to patients with dementia in an intermediate care hospital: pre-post quasi experimental study

OBJECTIVES

In persons with dementia, polypharmacy may be discordant with the goals of care. It is necessary to design interventions that align treatment regimens with the patient's situation, prognosis and preferences. The objectives of this study conducted at an intermediate care were to: i) identify inappropriate prescribing per the main care goal; ii) compare the pharmacotherapy data pre and post a medication review based on the degree of cognitive impairment; iii) assess the implementation of the proposed prescribing recommendations three months after discharge.

DESIGN

Pre-post quasi-experimental study.

SETTING AND PARTICIPANTS

Patients with dementia discharged from an intermediate care hospital between November 2021 and April 2022.

METHODS

Demographic, clinical and pharmacotherapy data were evaluated at admission. Medication reviews and interviews with the caregivers were conducted to align pharmacologic therapies with the overall goals of care. At discharge, information on the proposed prescribing recommendations was shared with the primary care team in the discharge summary. Follow up to evaluate implementation of the prescribing recommendations proposed during the medication review was performed at three months.

RESULTS

Of the 97 patients included, 94.8% had at least one inappropriately prescribed medication. At discharge, the mean number of chronic medications taken per patient decreased by 29.6%, from 8.05(SD 3.5) to 5.67(SD 2.7) (p < 0.001); the anticholinergic burden decreased by 18.6%, from 1.59(SD 1.0) to 1.29(SD 0.9) (p < 0.001); and therapeutic complexity decreased by 28.4%, from 29.23(SD 13.8) to 20.94(SD 11.3) (p < 0.001). At 3 months implementation of the proposed prescribing recommendations was 90.0%.

CONCLUSIONS AND IMPLICATIONS

Admission to an intermediate care hospital provides the ideal setting for a multicomponent intervention, tailoring prescriptions to the patient's overall goals of care and preferences, improving the pharmacotherapy parameters related to side effects, and ensuring that the proposed prescribing recommendations are maintained over the medium term.

Potentially Inappropriate Medication Use and Polypharmacy Before and After Admission to Internal Medicine for Older Patients

BACKGROUND

With the aging of the population and the increase in chronic diseases, there is an inherent risk of polypharmacy and inappropriate medication use. This study aimed to determine the prevalence and incidence of potentially inappropriate medication use and its correlation with polypharmacy.

METHODS

This was a retrospective, population-based cohort study among patients ≥ 65 years hospitalized at The National University Hospital of Iceland from 2010-2020. Data on medication usage were retrieved from the National Prescription Medicine Registry. Based on the number of medications filled in the year prior to admission and post-discharge, participants were categorized as non-polypharmacy (<5), polypharmacy (5-9), and hyper-polypharmacy (≥10). The prevalence and incidence of potentially inappropriate medication use was assessed based on the 2019 Beers criteria. Regression models were used to correlate sociodemographic, clinical, and pharmacoepidemiologic variables and the odds of new potentially inappropriate medication use.

RESULTS

The cohort comprised 55,859 patients (48.5% male) with a median [interquartile range] age of 80 [73-86] years. The prevalence of inappropriate medication use in the year preceding admission was 34.0%, 77.7%, and 96.4% for patients with non-polypharmacy, polypharmacy, and hyper-polypharmacy, respectively. The incidence of new potentially inappropriate medication use was 46.7% (95% confidence interval 45.6%-47.6%) among those with no potentially inappropriate medication use pre-admission. Factors associated with higher odds of new potentially inappropriate medication use after discharge were the use of multi-dose dispensing services, dementia, polypharmacy, and hyper-polypharmacy.

CONCLUSIONS

An increased emphasis is needed to review and reevaluate the appropriateness of medication use among the older population in internal medicine.

Deprescribing oral antidiabetics in elderly patients: Do electronic leaflets across the world address it?

Diabetes caused 6.7 million deaths in 2021, equating to one death every five seconds, with its global financial burden projected to rise from $1.32 trillion in 2015 to $2.12 trillion by 2030. Severe hypoglycemia necessitates interventions like deprescribing, behavioral strategies, and technology for prevention. Deprescribing aims to reduce unnecessary medication use, enhance rational prescribing, prevent prescribing cascades, and improve health outcomes in elderly patients. Evaluating electronic leaflets can support deprescribing based on patient-centered care and shared decision-making.

Objective

To analyze information on deprescribing in oral antidiabetic leaflets from national medicines regulatory authorities, focusing on elderly patients with type 2 diabetes.

Methods

This documental study analyzed electronic leaflets of oral antidiabetics from the official websites of nine Medicines Regulatory Authorities: Australia, Brazil, Canada, New Zealand, Singapore, South Africa, UK, USA, and EU, covering drugs listed in the WHO's Essential Medicines List 2023. The analysis focused on the alignment of deprescribing information with the Ontario deprescribing algorithm for oral antidiabetics developed by the Bruyère Institute in Canada.

Results

Out of 72 expected leaflets, 64 (88.9 %) were retrieved. Only 18 leaflets (28.1 %) explicitly discussed deprescribing oral antihyperglycemics. Hypoglycemia and drug interaction risks were addressed in 55 leaflets (85.9 %). Caution for use in patients over 65 was mentioned in 32 leaflets (50 %), and 23 leaflets (35.9 %) addressed the risks of tight glucose and HbA1c targets.

Conclusion

Despite a high retrieval rate, 11.1 % of leaflets were missing, and those available contained inconsistent deprescribing information. There are significant disparities in guidance across regulatory authorities. Standardized, updated leaflets that address deprescribing in frail older patients could enhance prescribers' confidence and support shared decision-making.

Effects of proactive healthcare on pain, physical and activities of daily living functioning in vulnerable older adults with chronic pain: a pragmatic clinical trial with one- and two-year follow-up

PURPOSE

To investigate the changes in pain, physical and activities of daily living (ADL) functioning in vulnerable older adults with chronic pain after proactive primary care intervention.

METHODS

This study was embedded in a prospective, pragmatic, matched-control multicenter trial at 19 primary care practices in Sweden, with proactive medical and social care (Intervention Group, IG, n = 134) in comparison with usual care (Control Group, CG, n = 121). Patients with chronic pain, defined as pain experienced longer than 3 months, were included in this subgroup analysis. Data on pain aspects, physical and ADL functioning were collected in the questionnaires at baseline, one- and two-year follow-up (FU-1 and FU-2). Data on prescribed pain medications was collected by local health authorities.

RESULTS

Mean age was 83.0 ± 4.7 years with almost equal representation of both genders. From baseline until FU-2, there were no significant within-group or between-group changes in pain intensity. Small adjustments of pain medication prescriptions were made in both groups. Compared to FU-1, the functional changes were more measurable at FU-2 as fewer participants had impaired physical functioning in IG (48.4%) in comparison to CG (62.6%, p = 0.027, Effect Size φ = 0.14). Higher scores of ADL-staircase (more dependent) were found in both groups (p < 0.01, Effect Size r = 0.24 in CG and r = 0.16 in IG).

CONCLUSION

Vulnerable older adults with chronic pain seemed to remain physical and ADL functioning after proactive primary care intervention, but they may need tailored strategies of pain management to improve therapeutic effects.

TRIAL REGISTRATION

ClinicalTrials.gov 170608, ID: NCT03180606.

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study

BACKGROUND

comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce.

OBJECTIVE

to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls.

DESIGN

complementary mixed-methods pre-post study, based on an embedded quasi-experimental model.

SETTING

geriatric fracture centre.

METHODS

qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing.

RESULTS

thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge.

CONCLUSION

as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.