Careful monitoring, communication important for deprescribing medications with weight loss
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Deprescribing medications can benefit patients with obesity, but providers must use caution to avoid hypoglycemia or hypertension for those with diabetes, according to a speaker.
“We definitely see some guidelines and recommendations around choosing medications that support, or at least don’t interfere, with weight loss,” Jeff Stanley, MD, medical director and clinical lead at Virta Health, said during a presentation at the Obesity Medicine Association 2021 Conference. “But at this point, there really haven’t been clear guidelines from organizations about how to deprescribe medications, particularly, in this case, diabetes or hypertension medications.”
Several clinical trials involving bariatric surgery, very low-calorie diets, plant-based diets and low-carbohydrate diets reported some data on the number of prescriptions deprescribed for participants. However, Stanley said most of the trials lacked specific protocols on the order of medications that were deprescribed, the pace at which medications were reduced and reasons why a medication was discontinued.
“Deprescription of medication is an area of growing interest, but there is little guidance on safe and effective deprescription for patients making dietary changes,” Stanley told Healio. “In patients with type 2 diabetes on medications such as insulin, deprescription is necessary to keep patients safe and avoid hypoglycemia or other complications.”
Guidance for discontinuing medications varies based on the type of medication involved. For diabetes medications, Stanley said avoiding hypoglycemia is the most important consideration. Providers should also set expectations and clarify goals with their patients. Hyperglycemia medications should be reduced aggressively, but Stanley cautioned against stopping all medications at the same time.
Unlike diabetes medications, blood pressure medications do not need to be preemptively reduced. Instead, providers can adjust them based on a person’s medical history and side effect profile of the medication. Providers should also start deprescribing with just one medication, reduce the dosage by half, and then monitor.
Statins are not commonly deprescribed, Stanley said, because guidelines recommend these important agents to prevent cardiovascular events. However, he added that it is common for patients to have concerns regarding statin adverse effects. For patients who want to discontinue a statin, providers should have an informed consent discussion about the risks, benefits and adverse effects with alternative agents. Stanley said providers should use the Mayo Clinic Statin Choice Decision Aid to help people understand their individual risks.
In addition to medication-specific guidance, providers should follow several general tips when reducing a patient’s medications.
“Close monitoring of blood glucose is extremely important as patients make dietary changes,” Stanley told Healio. “Medication reductions often occur daily in the early stages and are necessary for avoiding dangerous hypoglycemia. Patients should be made aware of the possibility of normal glucose without medications.”
Although it is important to monitor patients for saftey during deprescribing, Stanley said the process varies for each person. Providers must communicate with patients to determine which approach will work best.
“Deprescribing is incredibly rewarding for patients as well as for the provider,” Stanley said during the presentation. “When I’m messaging someone, when I’m calling someone, telling them you no longer need to take your insulin, I’ll hear from people that they are crying, or it is one of the best days of their life. It’s super rewarding for me as well to be able to give them that ability to navigate through that pass safely and to improve their health in the long term.”
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Stanley J. The Art and Science of Deprescribing. Presented at: Obesity Medicine Association 2021 Conference; April 21-25, 2021 (virtual meeting).
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