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enrique gaviln
general practitioner

VI jornadas uso adecuado

medicamentos Plasencia 3 nov 2011

research department polypharmacy laboratory

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

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what how

is deprescribing?

to deprescribe? the basis?

whatre how

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

does

whatre

+ discontinuation drug removal / cessation drugectomy from polypharmacy to oligopharmacy

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cut off

pruning

logging

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extirpation

gotic deco

minimalism

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

therapeutic retirement

diagnosing indicating prescribing supplying following up deprescribing

therapeutic chain

prescribing

deprescribing

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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 patients preferences

must

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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.

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review be

complete list of drugs

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

medication

transitions
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

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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

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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

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Beers

criteria 0,25 mg/d, in heart failure

Examples:
- digoxin, - amitriptiline - long

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

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STOPP-START

criteria

Examples:
- 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

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explaining talking,

and involving

informing, and, above all, expectations, beliefs

listening
preferences, adapt

rythm to real posibilities

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enhancing

therapeutic adherence achievements

highlighting supporting detecting

recurrence or worsening

symptoms

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inappropriate

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

absence

ethics

criteria preferences

patients

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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 Jyrkk 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

60-64

65-69

70-74

75-79

80-84

85-89

90-94

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; 56:6875

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congestive heart failure requiring treatment with a diuretic or ACO inhibitors renal failure (serum creatinine > 150 mol/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;315:4648

N = 5804, 70-82 y Shepherd J, et al. Lancet. 2002;360:162330. Mangin D, et al. BMJ. 2007;335:285-7

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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

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ibandronate, etidronate
no studies in this age group

alendronate
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;57:32734. Chua WM. Ther Adv Chonic Dis. 20011;2:279-86

RR = 0.6 (0.40.9), p = 0.009

RR = 0.8 (0.61.2), p = 0.35

McClung MR, et al. NEJM 2001;344:33340

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;25:150611

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

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

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

disease

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

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given

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

more individualizing
time consuming

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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

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given

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

more feasible
less flexible

tala

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two

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

more

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outside

agent: greater objetivity, worse actual knowledge about patients 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

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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

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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:

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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 patients attitudes

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physician-patient relationship

not addressing deprescribing with patient / family not considering patients perpective

patient
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

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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 Minu Beatriz Gonzlez Marc Jamoulle and all of you