10 key points: Deprescribing


An emerging health researcher and award-winning academic pharmacist speaks with AJP about the deprescribing process

Dr Emily Reeve, from the Kolling Institute at Royal North Shore Hospital in Sydney, is a pharmacist and researcher currently working on guidelines to withdraw low-value medication in people with dementia.

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Dr Emily Reeve

She was recently named a finalist of the Bupa Health Foundation Emerging Health Researcher Award and awarded $5000 for her deprescribing project.

Dr Reeve has an impressive range of experience in the area: she developed the world’s first questionnaire to understand patients’ attitudes to deprescribing, and wrote the world’s first paper specifically on the ethics of deprescribing.

AJP spoke with Dr Reeve about why withdrawal from medications is important, the warning signs of inappropriate medications, and which drugs to look out for. Here are her 10 key messages:

  1. As we age both the potential benefits of medication use and the potential harms can change. Additionally, we may have new medical conditions and in turn new medications added which can lead to drug-drug and drug-disease interactions. Treatment and care goals will also alter with time. This means that medications which were appropriate when first prescribed when someone is 65 years old may not still be appropriate when someone is 80 years old.
  1. Quality use of medications involves both prescribing new medications and deprescribing medications which are no longer appropriate. Deprescribing is the process of withdrawal of inappropriate medications, supervised by a clinician with the goal of reducing polypharmacy and optimising health outcomes.
  1. Studies have found that approximately one out of every two older adults are taking at least one medication which is inappropriate – that is, it is exposing them to more potential harm than benefit, or it does not align with their treatment goals.
  1. People who are taking an inappropriate medication have a greater risk of harm including adverse drug reactions, falls, hospitalisation and mortality. Inappropriate medications can lead to a variety of what are called ‘geriatric syndromes’ including falls, delirium, frailty and incontinence. These may go unrecognised as an adverse drug reaction and instead attributed to a normal part of aging, which they are not.
  1. One of the easiest signs to identify is number of medications. In general, the more medications that a person is taking, the more likely it is that one of those medications is inappropriate and suitable for deprescribing.
  1. Any time that a person is unwell or there has been a change in their condition, whether the change has been gradual or abrupt, is a good opportunity for the clinical pharmacist to determine if the cause might be one of their medications. Another trigger for a medication review is when a patient has a change in their care goals, for example from prolonging their life to maintaining the quality of their life.
  1. There are certain medications which are known to be a high risk of causing harm in older adults. Examples include medications with sedative properties (e.g. benzodiazepines) and those with anticholinergic effects (e.g. drugs used for urinary incontinence, some antidepressants and others). These should be reassessed during a medication review to determine if the potential benefit outweighs the potential harm and aligns with their goals of care, and to make sure that the patient is aware of the potential harm.
  1. But it is not just high-risk medications which should be reassessed. If there is little to no benefit to continuing the medication, for example, if the condition has resolved, then it might be suitable for deprescribing.
  1. There are several tools available to clinical pharmacists to help identify potentially inappropriate medications and assist them in their review of the medications. For example, the Drug Burden Index (DBI), STOPP/START criteria, Beers criteria, Medication Appropriateness Index and others.
  1. Deprescribing may lead to several potential health benefits including resolution of adverse drug reactions, reduced falls risk and even possibly reduced mortality. A reduced number of medications may lead to improved adherence to their remaining medications and a reduced cost to the patient. But, more importantly, deprescribing may lead to improved quality of life through reduced burden of medication taking and the health benefits listed above.

“Overall, it is important to ensure that people are taking the right medications for them, which means stopping those that are no longer appropriate,” Dr Reeve concludes.

 

About the Bupa Health Foundation Emerging Health Researcher Award

The Bupa Health Foundation has invested almost $30 million since its establishment in 2005, supporting over 100 health projects so far.

Five finalists were chosen this year as Australia’s emerging health researchers, including Dr Emily Reeve.

“I believe Emily’s research has the capacity to make a big difference to health and quality of life for older people in Australia and internationally,” says Professor Sarah Hilmer, Head of the Department of Clinical Pharmacology at the University of Sydney, who nominated Dr Reeve for the award.

“The idea is that older people wind up on a lot of drugs that they accumulate through their lives, which may well have been prescribed in good faith and helped them when they were younger, but as they get older the risk-benefit equation changes and these drugs start to cause more harm than good,” she says.

“Supporting and funding emerging researchers is vital to our country remaining a leader in the field of health research,” says Bupa Health Foundation Executive Leader Annette Schmiede.

“Our 2016 Emerging Research Awards finalists have already made significant contributions that have been recognised at home and globally. I congratulate them on their achievements and work so far, and look forward to watching their potential progress on our society’s health and future.”

The winner, Associate Professor Gail Garvey from the Menzies School of Health Research, was awarded $20,000 towards her research into cancer treatments for Aboriginal and Torres Strait Islander people.

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