Polypharmacy especially in older people may lead to the use of medications that are unnecessary, ineffective, unsuitable or even harmful. Controlled deprescribing is a challenge Aducate seeks to tackle through a new training module.
The Centre for Training and Development, Aducate, at the University of Eastern Finland recently introduced a new training module that seeks to offer new guidelines for controlled deprescribing. The module is intended for pharmacy specialists in particular, and it can be completed as separate training or as part of professional development training in medication review.
Medication review is a multi-professional operating model where a specially qualified chemist or pharmacist reviews the patient’s medication regime and its problems, and makes a suggestion to the patient’s physician on how to optimise medication.
“When necessary, this should include a concrete deprescribing plan,” Coordinator Ville Valkonen, MSc Pharmacy, says.
“Qualified chemists and pharmacists can take an active role in supporting physicians during the deprescribing process. This is already being done elsewhere in the world, and there is a need to do this also in Finland,” Jonna-Carita Kanninen, MSc Pharmacy, says.
Polypharmacy is common especially among older people, as they are prescribed medications by multiple doctors. Medications can be prescribed not only to treat medical conditions, but also to combat side effects caused by other medications. On top of this, the patient may be using over-the-counter medications. The more medications the patient uses, the more likely it is for cumulative effects and side effects to occur, including tiredness, confusion and dizziness, which can predispose to falls. Older people, in particular, are susceptible to adverse effects, as the response to and elimination of medications from the body change with age.
Deprescribing can also become topical when the goals of treatment change, or when the patient is approaching the end of his or her life.
“For instance, is it necessary for someone who is confined to a hospital bed to use regular heart medication to prevent chest pain that occurs in physical strain? No medication should be continued without the need for it,” Valkonen points out.
“Medications that are potentially unnecessary get identified well, but deprescribing on a practical level remains challenging. Clear guidelines on when to initiate medication are often available, but there are no general guidelines for deprescribing individual medications,” Kanninen notes.
The symptoms caused by abruptly stopping the medication can be startling.
Systematic deprescribing proceeds according to a plan: one medication at a time is discontinued, while monitoring the patient’s response. Changes in medication can have an effect on the symptoms it was prescribed for, as well as on the effectiveness of other medications. Gradual reducing of the dose is often the best course of action.
“It is important that the patient knows what the deprescribing plan is, and that the patient is aware of the risks on the basis of which deprescribing is done. The patient’s own commitment to the plan plays a key role especially when deprescribing sleep medications, psychiatric mediations or strong analgesics.”
In addition, quitting regular over-the-counter medications, such as proton pump inhibitors taken for heartburn, can also call for patience.
“Many use them for a long time and on excessive doses, and the symptoms caused by abruptly stopping the medication can be startling,” Valkonen says.
“Deprescribing is a cyclic process where the situation is constantly re-evaluated. It is good to understand that deprescribing isn’t always successful.
Sometimes deprescribing is opposed by the patient or the patient’s family. Interviews with physicians reveal that the mere thought of discussing deprescribing can be difficult, and the threshold to deprescribing can be higher when the medication was prescribed by a fellow physician.
“A lack of evidence on controlled deprescribing has also been a bottleneck, but now we are starting to have the necessary evidence and tools. Indeed, Canada, for example, has issued nationwide guidelines on deprescribing,” Kanninen says.
The symptoms of a patient who uses multiple medications can, in fact, be caused by the medications rather than the illness. When side effects are treated with new medications, which can cause new side effects, a vicious cycle is born. This process is known as the prescription cascade. It is important to recognise unnecessary polypharmacy and to initiate controlled deprescribing.
The term deprescribing was coined in the early 2000s to refer to a systematic process, where the patient’s use of medications is reviewed, potential problems and needs for discontinuation are identified, and deprescribing is planned and carried out while monitoring the patient’s condition. Deprescribing is carried out in collaboration between the patient and his or her family, a pharmacy professional, a physician and other medical professionals.