Deprescribing as a Clinical Improvement Focus

Dharmarajan, T. S.; Choi, Hanbyul; Hossain, Nadia; Munasinghe, Uthpala; Lakhi, Fehmida; Lourdusamy, Dennisdhilak; Onuoha, Somechukwu; Murakonda, P.; Skokowska-Lebelt, Anna; Kanagala, M.; Russell, Robin O.

doi:10.1016/j.jamda.2019.08.031

Cited by 82 publications

(48 citation statements)

References 42 publications

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“…1,2 Delirium, syncope and falls are some examples of medication related harm which can lead to hospitalization of elderly patients. 9 Canadian health care system spends roughly $419 million on inappropriate medication use and $1.4 billion on negating the harm incurred from inappropriate medication use. 1 According to Canadian Institute for Health Information, about one third of the elderly population of Canada were taking five or more different classes of medications chronically in 2016, which is a significant portion of the population that could benefit from deprescribing.…”

Section: Deprescribing Contextmentioning

confidence: 99%

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

Elbeddini

Prabaharan

Almasalkhi

et al. 2021

Research in Social and Administrative Pharmacy

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Deprescribing aims to reduce polypharmacy, especially in the elderly population, in order to maintain or improve quality of life, reduce harm from medications, and limit healthcare expenditure. Coronavirus disease (COVID-19) is an infectious disease that has led to a pandemic and has changed the lives many throughout the world. The mode of transmission of this virus is from person to person through the transfer of respiratory droplets. Therefore, non-essential healthcare services involving direct patient interactions, including deprescribing, has been on hiatus to reduce spread. Barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. Some of these barriers can be mitigated by using the following interventions:patient education, prioritization of non-pharmacological therapy, incorporation of electronic health record (EHR), continuous prescriber education, and development of research studies on deprescribing. Currently, deprescribing cannot be delivered through in person interactions, so virtual care is a reasonable alternative format. The full incorporation of EHR throughout Canada can add to the success of this strategy. However, there are several challenges of conducting deprescribing virtually in the elderly population. These challenges include, but are not limited, to their inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. Virtual care is the future of healthcare and in order to retain the benefits of deprescribing, additional initiatives should be in place to address the challenges that elderly patients may experience in accessing deprescribing virtually. These initiatives should involve teaching elderly patients how to use technology to access health services and with technical support in place to address any concerns.

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Section: Deprescribing Contextmentioning

confidence: 99%

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

Elbeddini

Prabaharan

Almasalkhi

et al. 2021

Research in Social and Administrative Pharmacy

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“…"Deprescribing" is a programmed reduction in the drug number or dosage of inappropriate medications supervised by a health care professional, with a goal to reducing adverse outcomes. 48,55 The Choosing Wisely Canada recommendation on PPI therapy, updated in 2019, states: "Don't maintain long-term PPI therapy for GI symptoms without an attempt to stop/reduce the PPI at least once per year in most patients"; those with Barrett esophagitis and gastrointestinal bleeding would be exempt. 55 A review by nurse practitioners states that guidelines are not always clear, although adherence is emphasized; education of both patient and practitioner is hence paramount.…”

Section: Minimize Misuse: An Opportunity For Deprescribingmentioning

confidence: 99%

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

Dharmarajan

2021

Journal of the American Medical Directors Association

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Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided.The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth.Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using "on-demand" therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted.PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.

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“…Medications require reconciliation in appropriate settings including follow-up visits, hospital admissions, hospital discharge, and during transitions of care between care facilities or physician offices. Medication reconciliation can help address inappropriate medication use, polypharmacy, and the potential for adverse drug events and help initiate deprescribing (Serg et al 2011;George and Jacobs 2011;Dharmarajan et al 2020).…”

Section: Periodic Medication Review and Reconciliationmentioning

confidence: 99%

“…Deprescribing refers to a programmed and systematic approach to the reduction in dosage or discontinuation of redundant or inappropriate medications, following discussions and understanding between provider and patient; follow-up after deprescribing is a mandatory requirement. The process is one means designed to address polypharmacy and reduce adverse drug events (Dharmarajan et al 2020).…”

Section: Periodic Medication Review and Reconciliationmentioning

confidence: 99%

Comprehensive Geriatric Assessment

Dharmarajan¹

2021

Geriatric Gastroenterology

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Deprescribing as a Clinical Improvement Focus

Cited by 82 publications

References 42 publications

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

Comprehensive Geriatric Assessment

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