HPE HPE 90 – November 2018 | Page 21

medication wastage in addition to improving overall patient care. 6–10 There is emerging evidence that deprescribing can have benefits such as improved cognition, reduction in falls and improved quality of life. 11 Definition Deprescribing can be defined as “the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes.” 12 In order to initiate deprescribing, it is important to understand a patient’s comorbidities and their medications, through undertaking a thorough review of their medicines and assessment of compliance and adherence. 4 Vitamins and over the counter (OTC) medicines should not be overlooked; some OTC medicines can interact with the patient’s current therapy and be harmful to their health, for example, St John’s Wort, which can interact with a number of medicines. 13 Managing deprescribing Mangin et al describe the need to change our viewpoint when treating patients with multimorbidities by taking a more generalist approach in the management of their medicines and moving away from treating diseases in their own individual silos. 14 There is evidence to suggest that deprescribing can lead to improved outcomes for patients. 15,16 Initiation of deprescribing is associated with low relapse rates, with as low as 1.2% of discontinued medicines being restarted; this was also associated with a significant reduction in mortality and hospital referrals. 17,18 Deprescribing has also demonstrated improvement in cognition following withdrawal of various medicines, mainly benzodiazepines. 16,17,19 Some disease states, such as cardiovascular disease, diabetes and dementia, necessitate polypharmacy that is in line with guideline recommendations. Prescribers may not feel confident to deprescribe a medication in view of the patient’s past medical history, and as such, polypharmacy may continue. 20 This is also where prescribers might find it difficult to consider which disease takes priority, how to tackle this type of polypharmacy, and whether it needs tackling at all. Psychotropic medicines can increase the risk of falls and therefore should be reviewed on a regular basis to avoid long-term use, particularly in frail and elderly patients. 21,22 Deprescribing of unnecessary psychotropic medicines can result in a 66% reduction in the risk of falls. While deprescribing of psychotropic medications is advantageous, symptoms of withdrawal might hinder the process and often patients are reluctant to reduce and discontinue their psychotropic medication. 23 Dementia is often associated with behavioural and psychological symptoms and as a result psychotropic medications are often prescribed in this instance. A multidisciplinary approach to deprescribing in such a scenario is warranted to overcome challenges and address this type of polypharmacy. 22 In patients with limited life expectancy or in those who are considered end of life, deprescribing of non-critical medications should be considered. Statins, for example, demonstrate benefit in reducing cardiovascular morbidity and mortality over a number of years; therefore their use in such cases is unlikely to confer any benefit and could be discontinued. 24,25 Fundamental to the process of deprescribing is a paradigm shift in the way in which healthcare providers view the prescribing and administration of medications Anticholinergic drugs can have a detrimental effect on an individual’s cognition, particularly in the elderly, and can cause side effects, such as increased heart rate and blurred vision, that can contribute to an increased risk of falls. 11,27 Anticholinergic receptors are present in the central nervous system and throughout the body, and can therefore cause unintended effects. Elderly patients with comorbidities are more susceptible to these unwanted effects. 28 Aging Brain Care has produced a scale in order to calculate the Anticholinergic Cognitive Burden (ACB) and consider the existing burden when initiating new medicines. Anticholinergic use may be linked to an increased risk of cognitive impairment, 29 decline on the Mini- Mental State Exam and increased risk of death. 30 The vast number of medicines prescribed in primary care have some degree of anticholinergic activity and the burden is high in patients who are prescribed multiple ‘low’ or ‘possible’ anticholinergics (as defined by Aging Brain Care) and therefore might not be as apparent to general practitioners (GPs). 31 This demonstrates the need to increase awareness of the ACB and its potential impact on a patient as shown in Table 1. Proton pump inhibitors (PPIs) are often prescribed inappropriately. PPIs have been associated with the increased risk of Clostridium difficile 32,33 and other adverse effects such as increased risk of fractures, kidney disease and community-acquired pneumonia. 34 Gradual withdrawal of PPIs with no adverse effects or rebound symptoms following four weeks of cessation has been demonstrated, 35 and numerous studies note the inappropriate prescribing of PPIs and therefore should remain a drug of interest when considering deprescribing. 36–38 A paradigm shift is required in the prescribing process, and the concept of deprescribing should be considered at the point of prescribing in a four step deprescribing process; “(1) recognising an indication for discontinuing a medication; (2) identifying and prioritising the medication(s) to be targeted for discontinuation; (3) discontinuing the medication along with proper planning, table 1 Commonly prescribed anticholinergics (as defined by Aging Brain Care) 52 ACB Score 1 (Possible) ACB Score 2 (Definite) ACB Score 3 (Definite) Atenolol, metoprolol Amantadine Cetirizine Carbamazepine Chlorphenamine Colchicine Nefopam Amitriptyline Clozapine Diazepam Oxcarbazepine Imiprimine Digoxin Nortriptyline Furosemide Olanzapine Hydralazine Oxybutinin Isosorbide Paroxteine Morphine Quetiapine Ranitidine Solifenacin Warfarin Trospium hospitalpharmacyeurope.com | 2018 | Issue 90 | 21