Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy

Abstract

Background: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor. Objective: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD. Design: Questionnaires and materials sent electronically. Participants: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists). Methods: A literature search was performed to develop the initial algorithms via Lynn’s method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn’s method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved. Results: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as “Agree” or “Strongly Agree” ranged from 84% to 95% (average of all five questions, across three rounds). Limitations: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools. Conclusions: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

“…A total of 9 medication-specific algorithms were created for alpha-1 blockers, benzodiazepines, gabapentinoids, loop diuretics, PPIs, prokinetic agents, quinines, statins, and urate-lowering agents (ULAs). 33 …”

“…A total of 9 medication-specific algorithms were created for alpha-1 blockers, benzodiazepines, gabapentinoids, loop diuretics, PPIs, prokinetic agents, quinines, statins, and uratelowering agents (ULAs). 33 The general rules contained in MedSafer included several of the aforementioned drug classes. However, these new guidelines had some additional rules (related to statins, ULAs, loop diuretics, and alpha-1 blockers) that could increase the number of PIMs identified by MedSafer in patients receiving dialysis.…”

Polypharmacy and Mental Health Issues in the Senior Hemodialysis Patient

“…Lefebvre et al have developed and validated nine deprescribing algorithms for HD patients. They published recommendations for deprescribing alpha-1 blockers, loop diuretics, proton pump inhibitors, quinine, statins, benzodiazepines and Z-medications, gabapentinoids, prokinetic agents, and urate-lowering agents ( 92 ). To the best of our knowledge, we have not found any deprescribing algorithms for antipsychotics or antidementia drugs specifically in HD patients, possibly due to lower rates of prescribing.…”

Education Standards for Pharmacists Providing Comprehensive Medication Management in Outpatient Nephrology Settings

“…Deprescribing is addressed as a separate education standard (II-5) since processes to facilitate deprescribing have been developed in the CKD population to reduce medication burden and/or prevent harm. 27 , 28 , 29 , 30 , 31 Deprescribing is the planned and supervised process of discontinuing medications that may cause harm or are no longer of benefit and may help to minimize use of potential nephrotoxic agents as well as those that may cause harm. The increased susceptibility of older individuals with advanced kidney disease to medication therapy problems prompted a separate education standard to focus on unique consideration to prevent such medication therapy problems in the geriatric population with kidney disease (II-6).…”