Issue 35 / 22 September 2014

LEADING doctors want to create a culture of “deprescribing” among the medical profession, saying inappropriate polypharmacy is a growing threat to Australia’s ageing population.

Two Clinical focus articles in this week’s MJA make a case for doctors to consider a careful trial of withdrawing potentially unnecessary medications, particularly in elderly patients and those taking 10 or more medications, noting that drugs initially prescribed appropriately can become inappropriate with ageing and new medical conditions. (1), (2)

Potentially inappropriate medicines included cardiovascular drugs, anticoagulants, hypoglycaemic agents, steroids and antibiotics, which accounted for large numbers of adverse drug events as a result of misuse, wrote Dr Ian Scott, director of internal medicine and clinical epidemiology at Brisbane’s Princess Alexandra Hospital, and his coauthors in the first MJA article.

While many people benefited from taking multiple drugs, many others suffered adverse events, they wrote.

The authors noted that up to 30% of hospital admissions for patients over 75 years of age were medication related, and up to three-quarters were potentially preventable.

“Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death; and reduced adherence by patients to essential medicines”, they wrote.

They listed barriers to deprescribing including under-appreciation by patients and prescribers of the scale of polypharmacy-related harm; multiple incentives to overprescribe; reluctance by prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about strategies to reduce polypharmacy

The single most important predictor of inappropriate prescribing and risk of adverse drug events was the number of medications a person was taking, with an 82% risk for people taking seven drugs or more. Yet 20% of older Australians received more than 10 prescription or over-the-counter medicines, the authors wrote.

Professor David Le Couteur, professor of geriatric medicine at the University of Sydney, praised the MJA focus on deprescribing, which he said deserved more attention from the professional colleges and medical schools.

“There is the opportunity to develop a systematic approach to providing education, guidelines and resources for deprescribing”, he told MJA InSight.

He also called for prescribing information to include details on deprescribing dosing schedules and withdrawal symptoms.

Professor Le Couteur said that in geriatric medicine, the first diagnosis to consider with any new symptom or disease was an adverse drug reaction, particularly confusion or dementia with anticholinergic drugs and falls with psychotropic drugs.

“I consider deprescribing in every older patient with a new symptom, those on hyperpolypharmacy [> 10 drugs], any patient on psychotropic medicines, and when there are changes in the patient goals related to dementia, frailty or end-of-life care”, he said.

Patients should be monitored in the same way after deprescribing as they would be after a new drug was prescribed.

“I don’t see deprescribing any differently from prescribing — it has risks and benefits, it needs consent and monitoring, it’s done to improve patient outcomes, how you do it will depend on the drug and the patient. The only difference is that deprescribing is cheaper”, he said.

Dr Justin Coleman, a GP at Brisbane’s Inala Indigenous Health Service and a representative on the NPS MedicineWise Choosing Wisely initiative, told MJA InSight deprescribing was primarily the role of the generalist.

“Just because a cardiologist or neurologist recommended starting two drugs last year doesn’t mean they are the best-placed expert when it comes to stopping the drugs now”, he said. “This is usually, and appropriately, the clinical decision of the regular doctor with the general overview.”

He said doctors should not wait for a specific, attributable side effect before ceasing a drug. “Reassessing the medications list only after a fall is like waiting for the heart attack before starting an antihypertensive”, he said.

The second MJA article examined the evidence for and against ceasing medicines, and concluded that while the data was limited, deprescribing was likely to produce more benefits than harms overall.

“Most of the harms of deprescribing can be minimised with proper planning (ie, tapering) and monitoring after the drug is discontinued, with reinitiation of the medication if the patient’s condition returns”, the authors wrote.

However, they warned that ceasing use of a medication could change the pharmacokinetics and pharmacodynamics of other medicines.

1. MJA 2014; Online 22 September
2. MJA 2014; Online 22 September

(Photo: Berna Namoglu, Shutterstock)


Poll

Should professional colleges and medical schools do more to educate doctors about deprescribing?
  • Yes – protocols urgently needed (88%, 135 Votes)
  • Maybe – more information needed (10%, 15 Votes)
  • No – not necessary (3%, 4 Votes)

Total Voters: 154

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12 thoughts on “Time to start deprescribing

  1. Debbie Rigby says:

    Great articles – congrats to all the authors. Deprescribing is part of quality use of medicines – safe, effective, appropriate and judicious use of medicines and should be seen as part of the medication management pathway. Home Medicine Reviews (HMRs), a collaborative service between GPs and pharmacists, is one way to address this issue in a patient-centred, collaborative way. 

  2. peter van maarseveen says:

    Every day I’m wondering when a statin is not needed anymore. If aspirin is still needed in a 90 plus nursing home patient.

     And it would be nice if there  were some guidelines on duration of medication. As doctors we are good on prescribing medication but not on stopping medication.

     

     

  3. Prof Avni Sali says:

    Wonderful article dealing with a major problem within the medical profession .Unnecessary prescribing is dangerous for the patient but also expensive medicine .Overprescribing is very likely to be one of the reasons why about half of Australians see an alternative non doctor practitioner rather than a GP .

    It is vital that GP’s who talk to their patients are rewarded for doing so rather than being rewarded to do a short prescripion consultation

  4. Dr Rohan Wilmott says:

    A good article. As a student many years ago I was attached briefly to a pharmacological review clinic at RBWH. This taught me to review all patient’s and their Rx regularly.

    As GP’s, we can do this as part of the regular patient consultations if we have the time & adequate remuneration. Patient’s with more than 10 medications (plus any homeopathics!) should be seeing their GP regularly anyway. So, rather than complete endless paperwork of various care & management plans, we should be able to do this more important aspect of care – indeed this was the way I was taught total patient care.

    The political concept requiring the completion of useless paperwork to jump through hoops to get minimal medicare funding on a few ancilliary services or on the currently politically trendy medical issue needs to be replaced by the concept of “old fashioned, holistic medicine”. If I have the time (ie adequate rebate for my time) to actually do proper history, examination & management of the patient, then prescribing, unprescribing, management & surveillance with prevention will naturally follow.

    So I’m all for unprescribing, as long as we GP’s are treated like the well trained professionals we are. It is high time to get rid of the expensive, generally time wasting bureaucratic nonsense & get down to some proper medicine – know the patient, know the disease, do the management, be allowed to refer appropriately without all the time-wasting “Hoo-Ha”!

    The current medicare system pays me the same for 5.001 minutes for a basic chat & a script as it does for 19.99 minutes for a good history, examination & management. Go figure why there is a problem!

  5. Christopher Maclay says:

    I would like to add my congratuations to the author and editors. Doctors must not be ‘prescribers’. De-prescribing could be a memorable and feasable concept which could invigorate the debate on providing care as opposed to just prescribing. I can think of so many patients who are not only grateful for assessment and honest discusion re risks and benefits of current medications, but also benefit physically and mentally from cessation. Although I agree that current medicare funding models may not do enough to encourage more in depth and comprehensive consultation this is hardly an excuse we can hide behind as a profession. 10 Points.

  6. Sue Ieraci says:

    Important article – thank you! I am particularly interested in the prescription of preventative medications in the very elderly – especially statins and anticoagulants in the over-nineties, and too-tight control of blood pressure and blood sugar in this age group. Perhaps the very guidelines and KPIs that drive the prescription of these drugs could also drive their de-prescription. The new KPI could be ”percentage of eligible people commenced on (risk-factor modification therapy) PLUS percentage of people where (therapy) was stopped when the risk was likely to exceed the benefit. 

  7. Jane Tracy says:

     

    This is an important and worthwhile article and discusison. Another patient group in whom deprescribing is a very important aspect of care is people with intellectual disabilities who have been prescribed medication because of some sort of change in their behaviour. Such behaviour change may have been the only way they could express their distress or discomfort relating to physical illness, disorders of mental health, dental/oral pain, changes in their physical or social environment, sensory sensitivity or their reaction to loss and grief. Too often antipsychotics are prescribed to ‘treat’ the behaviour, and the tendancy is that they are then assumed to have a psychotic illness and the dose tends to creep up over the years. Deprescribing is a challenge – but its good medicine and saves side effects, interactions, unnecessary sedation …and dollars!

  8. Anne Todd says:

    This is a core part of the current program the undergraduate Medical Students in the clincial school I teach into as a pharmacist. It also forms part of the interprofessional learning experience in a number of clinical settings. Specifically in aged care setting we discuss de-prescribing using a number of tools such as the Beers Criteria , STOPP/START and Basger et al’s prescribing appropriateness criteria for older Australians and of course – the GP and pharmacist’s input into each tutorial session.

      For a really good summary with some good ideas about which medicines to deprescrbe or avoid in the elderly see the Aust Family Physician article “Thinking through the medication list” from 2012.

  9. Genevieve Freer says:

    Perhaps there is a need for also educating practice staff, pharmacists,  as well as patients that rather than expecting that the GP “just write the scripts-that is all I need ” that the reason that a prescription drug  by law  must be prescribed  by a doctor, is that prescribing confers a legal, medical and ethical responsibilty on the doctor in this country, in addition to  the cost of prescribing, of which all doctors are aware.

    I agree with Rohan, that Medicare rewards the 5 minute consultation, so the longer we see a patient, the less Medicare pays per minute. , while the cost of running a practice increases with every minute we pay staff, use power. Chris, this is not an excuse, it is an economic fact.

    Medicare should fund a medication review every 6 months for all chronic disease patients, with a rebate of at least $200 per review, if anyone is serious about deprescribing, which would be better described as optimised prescribing, from the point of view of improving patient well-being , reducing public hospital polypharmacy adverse drug reaction  admissions, reducing  the PBS budget, not to mention  improving the mental health of the hapless GP who is seen to be  to blame for all the inappropriate prescribing of the GP, the hospital , the specialist, and the numerous confusing  generic brands of drugs supplied to benefit the pharmacists’ and the PBS budgets.

     

     

  10. Debbie Rigby says:

    Rose, pharmacists and GPs are funded to conduct medicaton reviews in a collaborative model. Accredited pharmacists are funded $208.22 for a Home Medicine Review, for about 2-3 hours. GPs are funded $154.80 for Item 900 through Medicare. And they can be conducted every 6 months with chronic, complex patients – as long as there is a clinical need determined by the GP.

  11. Greg Hockings says:

    I was under the perhaps misguided impression that writing a repeat prescription is not a clerical chore, but rather a welcome opportunity to review the ongoing indication for the medication, check its efficacy and whether the patient has developed any adverse effects, and consider whether an alternative drug might be preferable if ongoing treatment is indicated. If this takes fifteen minutes, then charge the patient for fifteen minutes. Does anyone really think that the level of the Medicare rebate would be an acceptable ethical or legal excuse for not doing our job properly if a patient comes to harm from inappropriate prescribing?

  12. Genevieve Freer says:

    DRugby-the pharmacist in the rural town where I work does not do HMRs. 

    Greg, I agree, that the level of the Medicare rebate is no excuse for not doing our job properly, however, those of us who do the job properly should be remunerated adequately enough for us to stay in business. 

    When I refer a patient to a Physician, I request assessment and advice on treatment.

    Despite the typed referral containing a medication list, there appears to be a problem with some Physicians including those for whom English is their second language listing the medications on presentation, and then listing medications recommended after seeing the patient..

    It is not uncommon for patients to have high blood pressure / high BSL while seeing the  hospital specialist in clinic or as an inpatient.  Sometimes,  this is because  the patient has not taken medication prescribed, so the problem is solved by assisting the patient to take the prescribed medication, sometimes with the use of webster packs, sometimes with the use of a diabetes nurse educator, HMR if available .

    However, often medication is added unnecessarily, when compliance was the problem, not lack of medication, with resulting hypotension ,bradycardia,hypoglycaemia from polypharmacy.

    Perhaps prior to seeing the Physician, a medication review should be manadated prior to referral, and for inpatients, a medication review should be conducted by the hospital pharmacist  to ascertain whether the patient understands their medication, knows what they are prescribed, prior to discharge., then following discharge, a HMR should be mandatory, if you can source one.

     

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