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Special Communication | Less Is More

Reducing Inappropriate Polypharmacy The Process of Deprescribing

Ian A. Scott, MBBS, FRACP, MHA, MEd1,2; Sarah N. Hilmer, MBBS, FRACP, PhD3,4; Emily Reeve, BPharm (Hons), PhD4,5; Kathleen Potter, PhD, FRACGP6; David Le Couteur, PhD, FRACP7; Deborah Rigby, BPharm, GradDipClinPharm, FASCP, FACP, FAICD8,9; Danijela Gnjidic, PhD10; Christopher B. Del Mar, MB, BChir, MD, FRACGP11; Elizabeth E. Roughead, PhD12; Amy Page, MClinPharm13; Jesse Jansen, MPsych, PhD14; Jennifer H. Martin, MB, ChB, FRACP, PhD15
[+] Author Affiliations
1Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, Australia
4Kolling Institute of Medical Research, School of Medicine, University of Sydney, Sydney, Australia
5Cognitive Decline Partnership Centre, School of Medicine, University of Sydney, Sydney Australia
6Western Australia Centre for Health and Aging, Perth, Australia
7Ageing and Alzheimers Institute, Concord Hospital and Sydney Research, University of Sydney, Sydney, Australia
8National Prescribing Service MedicineWise, School of Pharmacy, University of Queensland, Brisbane, Australia
9School of Pharmaceutical Sciences,Queensland University of Technology, Brisbane, Australia
10School of Pharmacy, University of Sydney, Sydney, Australia
11Centre for Research in Evidence-based Practice, Bond University, Gold Coast, Australia
12School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
13School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
14Screening and Test Evaluation Program (STEP), Sydney School of Public Health, Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), University of Sydney, Sydney, Australia
15PA-Southside Clinical School, University of Queensland, Brisbane, Australia
JAMA Intern Med. 2015;175(5):827-834. doi:10.1001/jamainternmed.2015.0324.
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Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies. A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one; (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application.

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De Prescribing in the Vulnerable Population with Intellectual Disabilities.Comment on : Reducing Inappropriate PolypharmacyThe Process of Deprescribing
Posted on August 3, 2015
Bernadette Flood,M.P.S.I., B. Sc. Pharm, M.Sc. Primary Health Care, PhD Candidate.
Daughters of Charity Disability Support Services Dublin & School of Pharmacy Trinity College Dublin.
Conflict of Interest: None Declared
Comment on : Reducing Inappropriate Polypharmacy The Process of Deprescribing

De Prescribing in the Vulnerable Population with Intellectual Disabilities

Background:
The population with intellectual disabilities is a vulnerable population group in which medication use is the main therapeutic intervention. Prescribing and de-prescribing medications for patients with intellectual disabilities with multiple co morbidities and multiple medications is an extraordinarily complex endeavour. People with intellectual disabilities and their carers adjust to their health conditions and may value health states differently over time and from other population groups. When making decisions about medicines use in people with intellectual disabilities , the person must be treated and not the disease.

Four key strategies to support people with intellectual disabilities in obtaining information about medication have been identified - spending more time providing and reiterating key information, providing accurate, up-to-date, accessible information about medications, providing training for carers in wider aspects of medication usage, and tailoring information to each person's individual needs (Heslop et al., 2005).

Potentially Inappropriate Medication
People with intellectual disability are vulnerable to overprescribing of psychotropic medications in healthcare (Public Health England, 2015), have greater health needs and behaviour support needs than the general population. They have a different pattern of morbidity and mortality. They are more likely to experience mental illness and are more prone to chronic health problems such as epilepsy, cerebral palsy and other physical disabilities. Disparities in health care for people with intellectual disabilities have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it.

The classification of a drug as potentially inappropriate for patients with intellectual disabilities depends, not just on the level of evidence for risk, but also on the available alternatives and on the need for treatment. It would not be possible to designate medications and classes of medications used in people with intellectual disabilities to treat identified morbidity patterns as potentially inappropriate for the population with intellectual disabilities , as they may be absolutely necessary for the proper treatment of many “typical” diseases of people with intellectual disabilities.

In all population groups the risk of inappropriate use of medication is proportional to the number of medications prescribed. A considerable number of potentially inappropriate medications assessment tools have been developed. However many of these tools may be disappointing when used outside the context of their original validation and those effective in the circumstances in which they have been developed may not be found to be effective when used outside the place of development or in a population group with different characteristics . Poor external validation of some of these tools may exist. However, even when tools are properly externally validated, the characteristics of patient populations and staff vary.

The proper match between clinical conditions and medications in vulnerable populations is defined not only by guideline recommendations and best practices, but by how medication treatment for a given condition will help the patient attain the goals of care. The optimized medication regimen for a patient desiring a palliative approach that minimizes medication burden may look quite different than the regimen for a similar patient with the same conditions whose overriding goal is maximizing longevity (Steinman and Hanlon, 2010).

Suboptimal prescribing in this vulnerable population group may be defined as the use of medications with the potential for risk to outweigh benefits to the patient and it may be divided into 3 categories: overuse, misuse, and underuse. All three categories have the potential to cause adverse patient outcomes. While overuse and misuse of medications may result in an increased risk of adverse reactions, drug-drug interactions, and drug-disease interactions, the failure to prescribe essential medications may result in the worsening of an illness or therapeutic failure. Therefore, it is important that suboptimal prescribing in this population group be identified. Medical technologies such as medications differ greatly in terms of clinical outcomes in people with intellectual disabilities. The safe use of psychotropic medications does require proper treatment monitoring and dose adjustment. There are also non health factors related to treatment with medication in this population that should be considered: quality of life, productivity, functioning, satisfaction and other patient-centred outcomes.

Conclusion
Those considering de-prescribing medications in the vulnerable population with intellectual disabilities and behaviour disorders may consider principles of de-prescribing below, based on the principles of prescribing of the British Pharmacological Society.

Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities Based on the British Pharmacological Society’s Principles for Good Prescribing (British Pharmacological Society, 2010).

1. Be clear about the reasons for de-prescribing
2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing
3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders
4. Take into account the patient’s/ carer’s/ families/ advocates ideas, concerns, and expectations .
5. Ensure all medicines are effective, safe, cost-effective in appropriate form individualised for the patient with intellectual disability, behaviour disorders and other conditions such as dysphagia, autism
6. Adhere to national guidelines and local formularies where appropriate. Use caution where the population with intellectual disability have not been considered in the guideline development process
7. Write unambiguous correct documentation detailing reason for de-prescribing
8. Monitor the beneficial and adverse effects of de-prescribing medicines and any effects on behaviour
9. Communicate and document all de-prescribing decisions and the reasons for them such as transferred to appropriate personnel such as GP, pharmacist, psychiatrist, specialist e.g. diabetes, epilepsy, carer and patient
10. De -Prescribe within the limitations of your knowledge, skills and experience of the population with intellectual disabilities and behaviour disorders.

References:

BRITISH PHARMACOLOGICAL SOCIETY 2010. Ten Principles of Good Prescribing. London.
HESLOP, P., FOLKES, L. & RODGERS, J. 2005. The Knowledge People with Learning Disabilities and their Carers have about Psychotropic Medication Tizard Learning Disability Review, 10, 10-18.
PUBLIC HEALTH ENGLAND 2015. Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England.
STEINMAN, M. A. & HANLON, J. T. 2010. Managing Medications in Clinically Complex Elders: \"There's Got to Be a Happy Medium\". JAMA, 304, 1592-1601.
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