Reversing the 'prescribing cascade': Best practices for deprescribing

Key takeaways:

• Responsible medication use includes deprescribing medications when the risks outweigh potential benefits.
• An ACP presenter discussed what PCPs need to know about reducing the number of medications patients take.

NEW ORLEANS — Deprescribing can help streamline patients’ medications and improve quality of life, according to a presenter here.

“We often start medicines because of guidelines and trying to do the right thing,” Cynthia Boyd, MD, MPH, FACP, a professor of medicine, epidemiology and health policy and management at Johns Hopkins University, said in her presentation at this year’s annual ACP Internal Medicine Meeting. “When we start medications, it feels — both to the provider as well as the patient — that we're trying to directly address the problem. It feels helpful.”

But when patients have multiple chronic conditions and providers managing them, well-intentioned practices can become a pharmacological snowball, Boyd, who is also director of the division of geriatric medicine and gerontology at Johns Hopkins, said. Research indicates that more than one-third of older adults take a minimum of five medications every day, and 17% take at least double that.

“I actually once had a patient who said to me that she would take three medicines that I could choose, but she only wanted to take three,” Boyd said. “I think this illustrates what some patients experience when they're taking a lot of medications, which is this concept of that it feels like too much. There are other reasons that we might want to think about deprescribing: drug interactions, disease interactions and so forth.”

Somewhere between 15% and 40% of frail older adults have drug-disease interactions, according to data Boyd shared. And many times, “older adults receive a guideline-recommended drug to help one condition that may worsen another,” she said.

“This is a concept called a prescribing cascade, if the response to that worsening of the second condition is an additional medicine,” Boyd continued. “These problems obviously exist across the age span, but aging is where it is most common and arguably the most harmful.”

In these cases, providers may look to streamline the patient’s medications by deprescribing — “a structured, supervised process of withdrawal, dose reduction or substitution of an inappropriate medication with the goal of improving health outcomes and quality of life,” she said.

Boyd stressed that providers must balance the benefits and harms of any medication before prescribing or deprescribing, and consider the patient’s treatment goals, values and preferences.

“We also need to think about the pill and administration burden and cost,” she said. “I take care of a lot of patients who have dementia, and the number of times and the number of pills that you can be trying to get someone with dementia to take I think actually can affect quality of life both for the patient and caregiver. I don't think we can ignore that piece.”

In the deprescribing process, Boyd said primary care physicians should first determine what the patient is actively taking and if the medications are appropriate. Is the patient using the medication correctly? Is it providing a benefit? Is there evidence of a lack of efficacy or an adverse reaction? Ideally, these questions can help avoid prescribing cascades.

If deprescription is indicated, she said talking to the patient about medication tapering is the next step.

The specifics of tapering will vary from medication to medication. This is what can make deprescribing so challenging, Boyd said — there is not clear guidance on how to streamline patients’ medications.

“This is a field that I think is still emerging, in part because of how hard it actually is to do in practice,” she said. “This is really an area where I think more work is needed.”

However, Boyd mentioned several resources that PCPs can use for deprescribing:

• a clinical flow chart from the American Academy of Family Physicians;
• algorithms and flow charts from the Canadian deprescribing network; and
• the U.S. Deprescribing Research Network.

References:

• Guthrie B, et al. BMC Med. 2015;doi:10.1186/s12916-015-0322-7.
• Lindblad CI, et al. Clin Ther. 2006;doi:10.1016/j.clinthera.2006.08.006.
• Qato DM, et al. JAMA Intern Med. 2016;doi:10.1001/jamainternmed.2015.8581.