Cristina Roure, Pharmacist and Vice President of Acadèmia de Ciències Mèdiques i de la Salut de Catalunya i de Baleares will explain a "deprescribing" project in her own hospital (Hospital de Terrassa). She also filled my desk with references that do no more than highlight the interest in combating, from the professional, clinical and pharmaceutical perspective, the polymedication of frail and elderly people. From all the references that I consulted, I have chosen a New Zealand-Australian source that I will summarize next.
In New Zealand it has been estimated that 30% of people over 74 take five or more drugs, and about 10% take 10 or more. The drugs, says the reviewed publication, are often prescribed by different specialists, each of whom has followed a specific clinical practice guide for a condition or illness. Let's exemplify with a 70 year old woman suffering three chronic diseases and a couple of risk factors. This woman could easily be taking 19 daily doses of 12 different drugs at 5 different times of day, with a chance of generating 10 or more interactions.
There is a cohort study concerning the deprescribing prepared with the help of 70 people living in nursing homes (Garfinkel 2010), to which the "Good Palliative-Geriatric Practice Algorithm" has been applied. In this intervention group, polypharmacy was reduced and this in turn reduced morbidity and mortality rates. Another reference to deprescribing, well known in the world of geriatrics, comes from an Australian clinical trial led by Dr. Christopher Beer (Beer 2011) with a gradual medication withdrawal intervention in people 80 years (+/-11 ) taking 9 drugs (+/-2) and concluded that the reductive action was feasible and desirable.
According to Dr. Mitchell Katz, editor of JAMA Internal Medicine, the protocols of deprescribing are a clear example of the section "Less is more”, which drives the magazine.
Reconciliation and deprescribing
Medication reconciliation is a practice that aims to detect errors and repetition, but that does not question the indication. Deprescribing, however, is a critical and structured review of the patient's treatment regimen that aims to adjust both the evidence and each person’s lifestyle.
The deprescribing process is structured around the following concepts:
- Evidence supporting each of the drugs indications
- Patient's life expectancy
- Prioritization of health problems that affect them
- Patient’s opinion and his/her expressed commitment to the specifics
- Individualized evaluation of benefits and risks for each drug
- Non-pharmacological alternatives to address specific problems
- Development of a gradual plan of deprescribing that can also be monitored
The Hospital de Terrassa project
The study called "Clinical validation of a standardized methodology for the medication review of deprescribing in polymedicated complex chronic patients", lead by Crisitna Roure, aims to evaluate the effectiveness of a methodological deprescribing guide. The project proposes an intervention in 105 patients with chronic polymedication with an overall project duration of 2 years.
It seems clear that complex chronic patients need an individualized therapeutic approach, rather than a string of recipes from various specialists. All studies are telling us that often the problems of polymedication are worse than the benefits of each particular drug.
Both the Australian projects and the study from Hospital de Terrassa take a professional approach to the issue, verifying evidence, adjusting the indications to the expectations of life and values of patients, prioritizing the problems to combat, evaluating benefits, watching interactions, etc. This is a commendable project that requires training and multidisciplinary work.
We have seen the polymedication epidemic in older people and the fact that for now we have only discussed about how to combat the problem, we now need to reflect on whether prevention is possible or not. I believe that only the clinical leadership in primary care (with an important role by the nurse), with the scientific support of a geriatrician when necessary, ensure a realistic approach to the needs of the elderly, the basis for the promotion of healthy attitudes and adjusted therapies.
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Adressing polipharmacy. Arch Intern Med, Oct 11 2010;170(18):1648-54.
Beer Ch, Loh P, Peng YG, Potter K, Millar A. A pilot randomized controlled trial of deprescribing. Ther Adv Drug Saf 2011; 2(2):37-43.