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enrique gavilángeneral practitioner
researchdepartment
polypharmacylaboratory
VI jornadasuso adecuadomedicamentos
Plasencia3 nov 2011
www.polimedicado.com / [email protected]
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what is “deprescribing”?
how to deprescribe?
what´re the basis?
how to desprescribe? who? by whom?
does it works?
what´re the risk / barriers / threats?
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discontinuation
drug removal / cessation
drugectomy
from polypharmacy to
oligopharmacy
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cut off
pruning logging
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extirpation
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+ gotic deco
minimalism
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therapeutic retirement
How? Fernandez did not
come to work becausehe´s been buried? Well, Ihope he do not forget tobring a certificate!
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deprescribing
following up
supplying
prescribing
indicating
diagnosing
therapeutic chain
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deprescribingprescribing
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process of adaptation of drugregimen: tappering, replacing,eliminating drugs
must take in consideration thescientific evidence, social and physicalfunction, comorbidity, quality of life and
patient´s preferences
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1. review, review and again review
2. reconsider therapeutic plan
3. taper off, eliminate, substitute
4. agree with the patient / caregiver
5. 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 complete list of drugs
be careful with over the counter drugs,naturopathics, non solid drugs
medication reconciliation in medicaltransitions
poor congruence with patient (58%)
Bikosky RM et al. JAGS. 2001;49:1353-7
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Holmes H, et al. Arch Intern Med. 2006;166:605-9
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Hardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51
review the indication (active?, goals?,time to benefit?)
analize the compliance degree
detect adverse effects (present and risk)
detect drug-drug and drug-disease
interactions
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no longer used drugs
drugs for inactive or cured diseases
those that caused adverse effects
those that pottentially would causerelevant harms
vicious drug waterfalls
Woodward MC. J Pharm Pract Research. 2003;33:323-8
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Beers criteria
Examples:
- digoxin, 0,25 mg/d, in heart failure
- amitriptiline –anticholinergic andsedative properties-
- long life benzodiazepines –fall risk andsedation-
Fick DM, et al. Arch Intern Med. 2003;163:2716-24
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STOPP-START criteria
Examples:
- thiazides if history of gout
- NSAID if uncontrolled HBP, renalfailure or gastric bleeding
- bladder antimuscarinics if history of dementia or glaucoma
Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46:72-83
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Maddison AR, et al. Prog Palliat Care. 2011;19:15-21
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explaining and involving
talking, informing, and, above all,listening
preferences, expectations, beliefs
adapt rythm to real posibilities
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enhancing therapeutic adherence
highlighting achievements
supporting
detecting recurrence or worseningsymptoms
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inappropriate polypharmacy as a publichealth problem
absence of scientific evidence for certaindrugs
ethics criteria
patient´s preferences
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Wilcox SM, et al. JAMA. 1994;272:292-6. Rollason V, Vot N. Drugs Aging.2003;20:817-32
40% of institutionalized & 25% of outpatientelderly has at least one inappropriate drug
20% >70 years use 5 or more drugs difficult adherence, adverse effects,
interactions, falls, morbidity, hospitaladmissions…
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Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31
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N = 339. Age > 80 yJyrkkä et al. Drugs Aging. 2009; 26:1039-48
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are thereelderly in
clinicalstudies?
what tellsthe
studies?and the
guidelines?
are thereevidences?
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Lee PY, et al. JAMA. 2001;286:708-13
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60-64 65-69 70-74 75-79 80-84 85-89 90-94
10
20
30
%
patients included in clinical trials
general population with dementia
age (years)Schoenmaker N, Van Gool WA. Lancet Neurol. 2004;3:627-30
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RR = 0.82 (0.69-0.99)NNT = 46 (637- 24)
HYVET Study. Beckett NS, et al. NEJM. 2008;358:1887-98
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Carey EC, et al. JAGS. 2008; 56:68–75
• dependence personalhygiene: 1 point• dependence indressing: 1-3 points• malignant disease: 2points• congestive heartfailure: 3 points• COPD: 1 point• renal failure: 3 points
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• congestive heart failure requiring treatment witha 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/
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Van Bemmel T, et al. J Hypertens. 2006;24:287-92
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Iyer S, et al. Drugs Aging. 2008;25:1021-31
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Walma EP, et al. BMJ 1997;315:464–8
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Shepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7
N = 5804, 70-82 y
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The fallacy of cheating death hasbeen 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
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Hello, guy! How well you've come!
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Emslie C, et al. Coronary Health Care. 2001;5:25-32Mangin D, et al. BMJ. 2007;335:285-7
if it occurs in young patients: fast death,without suffering
in the elderly: a natural dying, “a good wayof dying"
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• ibandronate, etidronateno studies in this age group
alendronate
only one trial that includes >80 y women: RRR non vertebral fractures46% (not as end point) (Pols 1999)
• risedronate- secondary prevention: RRR in morphologic vertebral fractures81%, 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%, noeffect on hip fracture (Lyles 2007)
- primary prevention, 37% > 75 y: RRR morphologic vertebralfractures 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
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McClung MR, et al. NEJM 2001;344:333–40
RR = 0.6 (0.4–0.9), p = 0.009 RR = 0.8 (0.6–1.2), p = 0.35
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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
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Black DM, et al. JAMA. 2006;296:2927-38
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Lai SW, et al. Medicine.2010;89:295-99
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Boyd CM, et al. JAMA. 2005; 294:716-24
disease
Information
about elderlypatients?
Information
about multiplecomorbidity?
Information
about elderlywith multiple
comorbidity?
diabetes mellitus Yes Yes Yes
hypertension Yes No Noosteoartrhitis Yes Yes Yes
osteoporosis No No No
COPD No No No
atrial fibrilation Yes Yes Yes
congestive heart failure Yes Yes Noangina Yes Yes Yes
hypercholesterolemia Yes Yes No
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hypothetic patient. 79 years, hypertension, COPD, type 2diabetes, osteoporosis and osteoarthritis (all moderate)
Boyd CM, et al. JAMA. 2005; 294:716-24
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Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52
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terminal patients: symptoms and personal care(no pain, no anxiety, no dyspnea, personalhygiene), preparation for death, stay mentally alert
elderly: willingness to take preventive medicationsis very unsensitive to benefits but high sensitive toadverse 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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poda
given a particular patient, reconsider the therapeutic regimen, deprescribingthe unnecessary drugs
moreindividualizing
timeconsuming
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do the benefits outweigh the risks?
exceeds the life expectancy of this
patient the drug time to benefit? is it a logical piece in the current
treatment regimen? Compare theindications for the drug and the goalsof this patient care
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Garfinkel D, Mangin D. ArchIntern Med.
2010;170:1648-54
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tala
given a particular inappropriate drug,review every patient that uses it and act
morefeasible
less flexible
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outside agent: greater objetivity,worse actual knowledge about patient´senvironment
bedside health proffesional: greater acceptance (trust, longitudinal attention,accessibility)
Moen J. Patient Educ Couns. 2009;74:135-41
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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, noblind evaluation, selection bias…
Garfinkel D, et al. Isr Med Assoc J. 2007;9:430-4. Garfinkel D, Mangin D. Arch InternMed. 2010;170:1648-54. Beer C, et al. Ther Adv Drug Safe. 2011;2:37-43
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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 or discontinue gradually
better in those with few drugs for aspecific process
close follow up at the beggining
“opened door”
shared decisions
flexibility: any change is irreversibleLeydon GM. Fam Pract. 2007;24:570-5
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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 patient´s attitudes
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physician-patient relationship
not addressing deprescribing with patient / family
not considering patient´s 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 or assymetry in decisionmaking (i decide, then i inform you )
forgetting the non-pharmacologicalaspects (psychological, social andfamily context, health systemperformance, expectations, clinicalrelationship ...)
Barsky AJ. Arch Intern Med. 1983;143:1544-8
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firstly, non-pharmacological approach
seeking the causes of the causes (fundamentalcauses)
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
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anticipate possible adverse effects
unbiased sources of information and learning
enhance adherence
patient-centered clinical outcomes rather thansurrogate or intermediate markers
remove the needless drugs
promote conservative desires and healthyskepticism in patientsSchiff GD, et al. Principles of conservative prescribing. Arch Inter Med. 2011
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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