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For patients with diabetes, consider ‘deprescribing’ to improve outcomes
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INDIANAPOLIS — A provider considering prescribing or recommending a new medication for a patient with prediabetes or diabetes should also consider eliminating at least one therapy the patient is already taking, according to a speaker here.
Patients admitted to the hospital, including those admitted for complications from diabetes, often are discharged with more prescription medications than they arrived taking, Rohit Moghe, PharmD, MSPH, CDE, an advanced practice pharmacist at Thomas Jefferson University Hospital in Philadelphia, said during a presentation at the American Association of Diabetes Educators. In many cases, Moghe said, an intensive focus on lifestyle intervention can allow for a provider to instead focus on “deprescribing” — reducing or eliminating unnecessary therapies that may, in the end, do more harm than good.
“The patient isn’t taking their medication and their blood glucose is not controlled — we add on another med,” Moghe said. “Their cholesterol is not well-controlled, and then we add on another med. Their blood pressure is not well-controlled, and then we add on another med. That leads us to polypharmacy. Once we have a patient on these multiple medications, that increases their risk for adverse drug reactions.”
‘ Not too much, not too little’
Moghe recalled a male patient with type 2 diabetes, aged 52 years, recently hospitalized with a blood glucose reading of 655 mg/dL and an HbA1c of 9.1%. The patient, diagnosed just 2 years earlier, reported taking 1,000 mg metformin twice daily and 10 mg glipizide twice daily. At discharge, he was additionally prescribed five more medications: lisinopril, atorvastatin, esomeprazole and escitalopram, plus cyclobenzaprine for low back pain.
“If I’m the pharmacist, I’m focused on the patient needing to know how to take these medications appropriately, to understand the benefits of taking these medications and their risks, but more importantly, the types of things he needs to do to enable these medications to work better,” Moghe said.
The greater public health point of view, however, should beg different questions, Moghe said.
“What if we could get this person to a state of health that he no longer needs me or these medications?” Moghe said. “Could that actually happen? I think the answer is yes.”
Patients, Moghe said, want to improve their condition, but typically don’t know the “what” or the “how” to make the necessary changes. Providers, Moghe said, have a role — to show patients how to make key lifestyle changes, including making healthier food choices, increasing physical activity, taking medications as prescribed, quitting smoking and reducing alcohol intake.
“All the drugs for diabetes are approved as an adjunct to diet and exercise,” Moghe said. “The FDA is clearly telling us we need to do better with diet and exercise, and I personally will add another caveat to that: stress management and sleep.”
Symptomatic patients with glucotoxicity do need to be treated more aggressively, Moghe said. The idea is to make treatment patient-centered.
“We should think about how long they have had this disease and get them on the right therapy — not too much; not too little,” Moghe said. “Something that they’re willing to do. That doesn’t just include medications. It can also include lifestyle management.”
Starting the conversation
Deprescribing, Moghe said, is a systematic process of identifying and discontinuing drugs in instances in which the existing or potential harms outweigh the existing or potential benefits.
“You’re not just taking a hacksaw to their medication regimen and chopping things,” Moghe said. “You’re doing this systematically. It is supervised by a health care professional. You’re not denying care. You’re doing this as a risk mitigation strategy, balancing the risk of continuing the treatment versus stopping it.”
The genesis for the deprescribing trend, Moghe said, comes from geriatric and long-term care communities in countries like Australia, Canada and New Zealand. All three countries have implemented the idea on a population-wide basis, Moghe said; he recommended the Canadian website www.deprescribing.org, developed by a Canadian pharmacist.
“Anytime you think about starting a medication, also think about stopping a medication,” Moghe said. “It can be done across all kinds of settings. It could be requested by the patient or it could be initiated by us.”
There are several “action steps” for deprescribing, Moghe said, beginning with a provider-patient discussion on the possibility of reducing medications after lifestyle changes. If the patient is receptive, the provider discusses goals; Moghe recommended using a motivational interviewing strategy that expresses empathy and explores priorities. To prepare, discuss the plan for deprescribing medications with the patient, and begin a referral process to a dietitian or certified diabetes educator to further discuss lifestyle changes, and to a pharmacist to further discuss medication changes.
“When reducing or stopping a medication, we have to counterbalance with what the medication’s original intent was,” Moghe said. “For example, if there is an antianxiety drug and the anxiety comes back (for the patient), we need to give them strategies to overcome this anxiety, some redirection.”
Providers must also make sure the patient has a good support system; resistance to lifestyle changes, Moghe said, often come from a patient being “stuck” in a comfort zone. – by Regina Schaffer
Reference:
Moghe R. Medication deprescribing in patients with diabetes after implementing lifestyle changes. Presented at: American Association of Diabetes Educators; Aug. 4-7, 2017; Indianapolis.
Disclosure: Moghe reports no relevant financial disclosures.