Polypharmacy, Medication Related Problems & Deprescribing
The single most important predictor of a medication related problem (MRP) is the number of medications a patient is taking, both prescription and OTC.
Once the number of medications exceeds 5, the incidence of a drug interaction or another MRP is >50%. This is important because we know utilization of medications per patient is up 1.4% in 2015 compared to the same time period in 2014 for NEPHO commercial members. Also, 41% of seniors take 5 or more medications, the definition of polypharmacy.
Deprescribing is the process of tapering or stopping drugs aimed at minimizing polypharmacy, improving outcomes and sometimes reducing costs for the patient. Deprescribing is an important part of the rational prescribing continuum.
- is a systematic process for discontinuing drugs where existing or potential harms outweigh existing or potential benefits within the context of an individual patient's care goals, current level of functioning, life expectancy, values and preferences.
- requires communication and collaboration among all health professionals including PCPs, pain specialists, mental health professionals etc., and patients and caregivers.
- is NOT about denying effective treatment or rationing
WHAT is the patient-centered Deprescribing process:
- obtain a comprehensive medication history
- identification of potentially inappropriate medications
- determine IF medication can be ceased
- plan and initiate withdrawal if needed
- monitor, support and document
Some barriers to Deprescribing:
For providers: Time, inertia, multiple prescribers, skill or
knowledge gap, goal of care, life expectancy
For patients: Fear, direct to consumer advertising
WHEN and WHY one should consider Deprescribing a medication:
- Changing priorities and needs at end-of-life
- Medication lacks a current indication
- Medication is associated with increased risk of potential harms with ongoing or long-term use
- Medication associated with drug/food interactions
- Medication is of low priority, relative to others, and there is a desire to reduce polypharmacy
- Discussion reveals medication is no longer desired or required by the patient (shared decision making)
WHAT are some medication categories for Deprescribing?
PPIs: useful in peptic ulcer disease and GERD; however, some do not require lifelong therapy that carries its own risk of harms & uncertainties. It is prudent to review for current indication &/or possible PPI discontinuation, e.g. after hospital discharge.
BENZODIAZEPINES: useful for the treatment of anxiety and short-term for insomnia; however, associated with increased risk of falls, and impaired cognition and function.
OPIOIDS IN CHRONIC NON-CANCER PAIN: when adverse events present and/or there is no improvement in function.
WHO would benefit from Deprescribing?
Older adults: a variety of factors result in older adults
being a prime group to assess for potential medications to deprescribe. Increased risk of medication-related problems (MRP) including drug interactions, medication burden, shortened life expectancy, frailty and changing priorities all give reason to reassess and reduce unnecessary polypharmacy when possible.
End of life / palliative care patients: as patients near the end of life, the emphasis often shifts toward optimizing comfort and quality of life. Medications that have been used for primary prevention of disease may be tapered and/or discontinued. It is usually appropriate to aim for less intensive management of conditions such as hypertension & diabetes, where the time-to-benefit falls into a longer timeframe. Consider Deprescribing the following meds in these patients:
- ASA, statins; possibly warfarin for atrial fibrillation
- Iron, vitamins, herbal/natural products
- Bisphosphonates (unless used for hypercalcemia with malignancy)
- Hormone therapy
- Anti-hypertensives and anti-hyperglycemics
2. RX Files Deprescribing Newsletter April 2015
3. Trends in Prescription Drug Use Among Adults in the United States From 1999-2012 Elizabeth D. Kantor, PhD, MPH; Colin D. Rehm, PhD, MPh et. al.
4. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus Jeremy B. Sussman, MD, MS et. al.
4. Scott, I. JAMA InternMed 2015
NEPHO Clinical Newsletter
Produced by Northeast Physician Hospital Organization
For more information contact:
Carol Freedman, RPh, MAS, CGP
Clinical Pharmacist NEPHO
Louis Di Lillo M.D., Northeast PHO Medical Director
Medication Adherence Tools
It is estimated there are about $200 billion dollars in preventable medication related costs a year. More importantly,
about 50% of those preventable costs are due to the lack of medication adherence.
Medication Adherence is the extent to which a person's behavior and process for taking medication corresponds with agreed recommendations from a health care provider.
Tools for improving a patient's medication adherence include pill boxes, blister paks, smart phone reminders etc. See the attached Medication Adherence Tools
list of local pharmacies providing medication delivery, pill packaging services and smart phone apps for improving medication adherence.
Medicare Part D 2016 Changes
All Medicare Part D prescription plans have an out of pocket deductible between $0 and $360 annually. Typically. the lower the monthly premium, the higher the deductible amount.
In 2016, the coverage gap (donut hole) begins once the patient and plan have spent a total of $3,310 on covered drugs, deductible, coinsurance, and copayment expenses.
Once in the coverage gap (donut hole), the patient pays 58% of the cost for generic drugs and 45% of the cost for covered brand-name prescription drugs. (e.g. atorvastatin ~$15 vs. Crestor $78 out of pocket during donut hole)
When $4,850 in total pharmacy expenses are reached, catastrophic coverage begins. Patients then pay smaller copays and/or coinsurance out of pocket costs
For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient's quality of life rather than as a disease control measure.