Deprescribing benzodiazepine receptor agonists taken for insomnia: a review and key messages from practice guidelines

Clinical decision-making in benzodiazepine deprescribing by healthcare providers vs. AI-assisted approach

AIMS

The aim of this study was to compare the clinical decision-making for benzodiazepine deprescribing between a healthcare provider (HCP) and an artificial intelligence (AI) chatbot GPT4 (ChatGPT-4).

METHODS

We analysed real-world data from a Croatian cohort of community-dwelling benzodiazepine patients (n = 154) within the EuroAgeism H2020 ESR 7 project. HCPs evaluated the data using pre-established deprescribing criteria to assess benzodiazepine discontinuation potential. The research team devised and tested AI prompts to ensure consistency with HCP judgements. An independent researcher employed ChatGPT-4 with predetermined prompts to simulate clinical decisions for each patient case. Data derived from human-HCP and ChatGPT-4 decisions were compared for agreement rates and Cohen's kappa.

RESULTS

Both HPC and ChatGPT identified patients for benzodiazepine deprescribing (96.1% and 89.6%, respectively), showing an agreement rate of 95% (κ = .200, P = .012). Agreement on four deprescribing criteria ranged from 74.7% to 91.3% (lack of indication κ = .352, P < .001; prolonged use κ = .088, P = .280; safety concerns κ = .123, P = .006; incorrect dosage κ = .264, P = .001). Important limitations of GPT-4 responses were identified, including 22.1% ambiguous outputs, generic answers and inaccuracies, posing inappropriate decision-making risks.

CONCLUSIONS

While AI-HCP agreement is substantial, sole AI reliance poses a risk for unsuitable clinical decision-making. This study's findings reveal both strengths and areas for enhancement of ChatGPT-4 in the deprescribing recommendations within a real-world sample. Our study underscores the need for additional research on chatbot functionality in patient therapy decision-making, further fostering the advancement of AI for optimal performance.

Polypharmacy in Multiple Sclerosis: Prevalence, Risks, and Mitigation Strategies

PURPOSE OF REVIEW

Polypharmacy, the use of ≥ 5 medications, is common in people with multiple sclerosis and is associated with negative outcomes. The use of multiple medications is common for symptom management in people with multiple sclerosis, but risks drug-drug interactions and additive side effects. Multiple sclerosis providers should therefore focus on the appropriateness and risks versus benefits of pharmacotherapy in each patient. This review describes the prevalence and risks associated with polypharmacy in people with multiple sclerosis and offers strategies to identify and mitigate inappropriate polypharmacy.

RECENT FINDINGS

Research in people with multiple sclerosis has identified risk factors and negative outcomes associated with polypharmacy. Medication class-specific investigations highlight their contribution to potentially inappropriate polypharmacy in people with multiple sclerosis. People with multiple sclerosis are at risk for inappropriate polypharmacy. Multiple sclerosis providers should review medications and consider their appropriateness and potential for deprescribing within the context of each patient.

Long-term use of benzodiazepines in chronic insomnia: a European perspective

Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.

Clinical Spectrum and Trajectory of Innovative Therapeutic Interventions for Insomnia: A Perspective

Increasing incidences of insomnia in adults, as well as the aging population, have been reported for their negative impact on the quality of life. Insomnia episodes may be associated with neurocognitive, musculoskeletal, cardiovascular, gastrointestinal, renal, hepatic, and metabolic disorders. Epidemiological evidence also revealed the association of insomnia with oncologic and asthmatic complications, which has been indicated as bidirectional. Two therapeutic approaches including cognitive behavioral therapy (CBT) and drugs-based therapies are being practiced for a long time. However, the adverse events associated with drugs limit their wide and long-term application. Further, Traditional Chinese medicine, acupressure, and pulsed magnetic field therapy may also provide therapeutic relief. Notably, the recently introduced cryotherapy has been demonstrated as a potential candidate for insomnia which could reduce pain, by suppressing oxidative stress and inflammation. It seems that the synergistic therapeutic approach of cryotherapy and the above-mentioned approaches might offer promising prospects to further improve efficacy and safety. Considering these facts, this perspective presents a comprehensive summary of recent advances in pathological aetiologies of insomnia including COVID-19, and its therapeutic management with a greater emphasis on cryotherapy.

Australian Consultant Pharmacists' Potential Roles in Sleep Health Care: Exploring a New Avenue for Improving the Management of Insomnia

BACKGROUND

The first-line treatment for insomnia is cognitive-behavioral therapy. However, there is persistent use of pharmacotherapy, particularly, sedative-hypnotics. Consultant pharmacists can provide medication review services for people using multiple medications. Therefore, they are well placed to provide sleep health/insomnia care with regard to sedative-hypnotic use and behavioral treatment recommendations/sleep health education. However, this avenue is, as yet, unexplored.

OBJECTIVES

To explore consultant pharmacists' current sleep health-related provisions and what their perspectives are around developing/implementing a consultant pharmacist-led behavioral service for insomnia.

METHODS

Qualitative semi-structured interviews were conducted with a convenience-based sample of consultant pharmacists. Interviews were audio-recorded, transcribed, and inductively analyzed.

RESULTS

Twenty-four consultant pharmacists were interviewed. Three themes were gauged: 1) Trivializing insomnia and sleep health, 2) Providing patient-centered care, 3) Service implementation - What do we need to consider? Participants commonly dealt with older patients and frequently encountered patients with sleep complaints/taking sleep medications. Generally, it was believed that sleep health was given minimal priority, with other comorbidities taking precedence in health provisions. Patients' attitudes toward management approaches were regarded critical to future treatment developments. While interested in expanding their sleep health/insomnia practice, participants expressed the need for appropriate education/training, funding, and collaborative treatment frameworks.

CONCLUSION

Insomnia/sleep health concerns are growing. Primary health professionals need to scale up their sleep health-care provisions to accommodate for this health demand. Consultant pharmacists are interested/willing to expand their sleep-related practice and provide evidence-based insomnia therapies; however, factors such as education/training, service configuration support, and patient attitudes should be addressed.

Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study

OBJECTIVES

Potentially inappropriate medications (PIMs) pose an increasing challenge in the ageing population. We aimed to assess the extent of PIMs and the prescriber-related variation in PIM prevalence.

DESIGN

Nationwide register-based cohort study.

SETTING

General practice.

PARTICIPANTS

The 4.2 million adults listed with general practitioner (GP) clinics in Denmark (n=1906) in 2016.

MAIN OUTCOME MEASURES

We estimated the patients' time with PIMs by using 29 register-operationalised STOPP criteria linking GP clinics and redeemed prescriptions. For each criterion and each GP clinic, we calculated ratios between the observed PIM time and that predicted by multivariate Poisson regressions on the patients. The observed variation was measured as the 90th/10th percentile ratios of these ratios. The extent of expectable random variation was assessed as the 90th/10th percentile ratios in randomly sampled GP populations (ie, the sampled variation). The GP-related excess variation was calculated as the ratio between the observed variation and sampled variation. The linear correlation between the observed/expected ratio for each of the criteria and the observed/expected ratio of total PIM time (for each clinic) was measured by Pearson's rho.

RESULTS

Overall, 294 542 individuals were exposed to 1 44 117 years of PIMs. The two most prevalent PIMs were long-term use (>3 months) of non-steroidal anti-inflammatory drugs (51 074 years of PIMs) or benzodiazepines (48 723 years of PIMs). These two criteria showed considerable excess variation of 2.33 and 3.05, respectively; for total PIMs, this figure was 1.65. For more than half of the criteria, we observed a positive correlation between the specific PIM and the sum of remaining PIMs.

CONCLUSIONS

This study documents considerable variations in the prescribing practice of GPs for certain PIMs. These findings highlight a need for exploring the causal explanations for such variations, which could be markers of suboptimal GP-prescribing strategies.

Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis

OBJECTIVES

Prevention of falls and fall-related injuries is a priority due to the substantial health and financial burden of falls on patients and healthcare systems. Deprescribing medications known as 'fall-risk increasing drugs' (FRIDs) is a common strategy to prevent falls. We conducted a systematic review to determine its efficacy for the prevention of falls and fall-related complications.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and grey literature from inception to 1 August 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of FRID withdrawal compared with usual care evaluating the rate of falls, incidence of falls, fall-related injuries, fall-related fractures, fall-related hospitalisations or adverse effects related to the intervention in adults aged ≥65 years.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently performed citation screening, data abstraction, risk of bias assessment and certainty of evidence grading. Random-effects models were used for meta-analyses.

RESULTS

Five trials involving 1305 participants met eligibility criteria. Deprescribing FRIDs did not change the rate of falls (rate ratio (RaR) 0.98, 95% CI 0.63 to 1.51), the incidence of falls (risk difference 0.01, 95% CI -0.06 to 0.09; relative risk 1.04, 95% CI 0.86 to 1.26) or rate of fall-related injuries (RaR 0.89, 95% CI 0.57 to 1.39) over a follow-up period of 6-12 months. No trials evaluated the impact of deprescribing FRIDs on fall-related fractures or hospitalisations.

CONCLUSION

There is a paucity of robust high-quality evidence to support or refute that a FRID deprescribing strategy alone is effective at preventing falls or fall-related injury in older adults. Although there may be other reasons to deprescribe FRIDs, our systematic review found that it may result in little to no difference in the rate or risk of falls as a sole falls reduction strategy.

PROSPERO REGISTRATION NUMBER

CRD42016040203.

Barriers and enablers to deprescribing benzodiazepines in older adults: elaborating an instrument and validating its content

OBJECTIVE: To elaborate and validate an instrument on barriers and enablers to deprescribing benzodiazepines in the patient’s perspective. METHODS: This study was conducted in 3 stages: (1) a methodological stage, (2) a semi-structured pilot interview with 25 older adults undergoing clonazepam deprescribing, and (3) content validation with the Delphi technique. Content validation was performed by 50 specialists with degrees and/or experience with primary health care and/or health care of older adults, such as physicians, pharmacists, and nurses. For evaluating the obtained results, we analyzed the concordance of evaluations with the coefficient of content validity (CCV). We considered values equal to or higher than 0.8 as acceptable levels of concordance. RESULTS: The instrument was considered validated in the first round of evaluation, where all items obtained a CCV of more than 0.8 in the specialists’ assessment. Nevertheless, they proposed improvements that were incorporated to the final version of the questionnaire. CONCLUSION: The instrument represents an important tool to be used by health care professionals for optimizing benzodiazepine deprescribing, with suitable levels of clarity and validity.

Why Z-drugs are used even if doctors and nurses feel unable to judge their benefits and risks-a hospital survey

BACKGROUND

Many patients receive Z-drugs for hospital-associated sleep problems, in spite of well-known risks. The aim of this study was to learn more about the attractiveness of Z-drugs, seen from the doctors' and nurses' perspective.

METHODS

Using a standardized questionnaire, doctors (63/116) and nurses (73/243) in a German general hospital were surveyed about the risks and benefits of Z-drugs, compared with benzodiazepines.

RESULT

"Reduced time to get to sleep" was perceived by doctors (51%) and nurses (53%) to be a strong benefit of Z-drugs; "confusion" and "falls" were perceived by ca. 10% of doctors and ca. 15% of nurses to be a frequent problem. Compared with benzodiazepines, respondents more often answered "unable to judge" for Z-drugs; e.g. for doctors, 18% (benzodiazepines) vs. 45% (Z-drugs) were unable to judge "improved daytime functioning" and 12% (benzodiazepines) vs. 37% (Z-drugs) were unable to judge "falls."

CONCLUSION

Z-drugs seem to be attractive because experiential knowledge overemphasizes their benefits and fails to take risks such as drug-related falls and confusion into account. Difficulties to judge a drug's risk-benefit ratio do not prevent doctors and nurses from using them. Interventions for reducing Z-drug usage should incorporate local quality assurance data about relevant patient risks.