Deprescribing

Physicians Express Unease Around Deprescribing, Suggest Changes

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Marcia Frellick

Most physicians sampled in new research agreed that although deprescribing among older adults is important, there are substantial barriers for doing so, and little incentive for making the changes.

Katharine A. Wallis, MBChB, PhD, from the Department of General Practice and Primary Health Care at the University of Auckland in New Zealand, and colleagues conducted 24 partly structured interviews with primary care physicians, who were invited to respond based partly on years in practice, employment status, and practice setting.

Their findings were published in the July/August edition of the Annals of Family Medicine.

1 in 5 Prescriptions Potentially Inappropriate

Primary care physicians do most of the regular prescribing, and high-risk prescribing in older patients is common: 1 in 5 prescriptions is potentially inappropriate in this population, the authors write. They add, “Up to 10% of hospital admissions result from drug-related problems, two-thirds of which are considered preventable through safer prescribing.”

Appropriate prescribing involves regular review of indicated medicines and tapering and withdrawing them when the potential harms outweigh the benefits.

But deprescribing comes with risks, including possible medical harm and potential harm to the relationships with patients and their families, according to the analysis of physician interviews.

Physicians interviewed reported uncertainty surrounding which medications patients were getting from different providers. Such uncertainty can lead to fear of adverse events from deprescribing. Fears also included reputational damage.

They also reported anxiety that patients and their families would be unhappy about deprescribing. Some expressed concern that patients and families could perceive the withdrawal of medicine to mean the physician is “giving up” or trying to cut costs at the expense of good outcomes.

One physician commented, “Sometimes people will say, ‘Why shouldn’t I have the same treatment that a younger person would have? You’re just writing me off’.’ ”

Another said, “There are people who see medication as the barrier between them and the grave.”

Also, in an effort to increase patient convenience and adherence, physicians have moved toward automatic refills, but although those are popular, they cut down on the chances to discuss medications.

Younger physicians in particular were reluctant to go against the prescribing practices of the patient’s other physicians, who may have more experience in prescribing.

Furthermore, disease-specific guidelines, the authors note, promote prescribing, not deprescribing.

The only real incentive for deprescribing is doing the right thing for the patient, the physician interviewees told the researchers.

Proposed Solutions

During the interviews, the physicians suggested many organizational changes to support deprescribing. Among them were making funding available to pay for annual medicine reviews, coordinating information sharing among providers on medicines, better availability for nondrug treatments, and computer alerts to remind physicians to review medicines.

“An alert would give you a little bit of courage to do it, or give you more reassurance, or give you a way to bring it up with the patient like, ‘Look, you see, the computer has noticed you’re on too many medications, maybe we can reduce it,’ ” one interviewee said.

Interviewees also suggested that when guidelines for diseases are updated they should include advice on when to stop medications and suggested patients should be encouraged to become more involved in managing their medications.

An interviewee suggested developing “[a] recall that sends out something to the patient every year and says, ‘Next time you’re at the doctor make sure to look over the pills.’ ”

Dr Wallis and colleagues conclude: “Interventions to support safer prescribing should consider the sociocultural influences, the importance to physicians of maintaining relationships, the sense of vulnerability many physicians feel in practice, and the myriad organizational constraints.”

The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2017;15:341-346. Abstract


Deprescribing medicines at end of life

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Almost half of older adults receive more than 10 prescription drugs in the last year of life.

“Physicians should consider discontinuing drugs that may be effective and otherwise appropriate but whose potential harms outweigh the benefits that patients can reasonably expect before death occurs.”

That’s according to the authors of a new study of more than 500,000 older adults which found, over the course of the final year of life, the proportion of individuals exposed to ≥10 different drugs rose from 30.3 per cent to 47.2 per cent. Analgesics, anti-thrombotic agents, diuretics, psycholeptics and β-blockers were the five most commonly used drug classes. More than a fifth received angiotensin-converting enzyme inhibitors and 15.8 per cent received statins during their final month of life.

Writing in the American Journal of Medicine the authors said polypharmacy raises important ethical questions about the potential futility of treatments close to death. “People with life-limiting illness often receive medications whose benefit is unlikely to be achieved within their remaining lifespan,” they said.

While deprescribing is supported by a growing body of evidence, the authors said firm guidelines are needed to support physicians in their decision to continue or discontinue drug treatments near the end of life. When deprescribing does occur, it requires “timely dialogue” with patients and their families, they said.