Rationalising medications through deprescribing
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l570 (Published 07 February 2019) Cite this as: BMJ 2019;364:l570All rapid responses
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Risk and fitness assessment before anaesthesia for elective surgery would seem to represent an ideal opportunity for a snapshot review of current medications. A fresh pair of medical eyes to detect drugs no longer necessary, or ones that may be causing harm. The mind behind those eyes however usually relies on intelligent guesswork about the reasons for prescriptions being started, and without knowing the full story is often reluctant to change anything except what has been an obvious oversight. An unknown hospital doctor seeming to ride roughshod over carefully thought-out care strategies and compromises, risks strengthening the walls between primary and secondary care, rather than the bridges.
We often think it better to simply mention to the patient that it would be reasonable for them to ask, when they next see their GP, whether a specific medication remains necessary or the best one for them. As prescribers we should all try to ensure that our patients clearly understand the reasons for our prescriptions, and also the circumstances under which they might be discontinued.
Competing interests: No competing interests
We read with interest the excellent article by Professor Avery and colleagues on the value and benefit of deprescribing. 1 Deprescribing should be integral to every clinician’s practice, and as such in 2013, the General Medical Council highlighted the importance of regular review of a patient's medication. Deprescribing should be undertaken by anaesthetists and intensivists, 3 and as such we are in a position to advise on the deprescribing of drugs that may have been commenced during critical illness eg amiodarone for atrial fibrillation or opioids for the management of post-surgical pain (PSP).
Poor deprescribing is pivotal in the the global prescribed opioid crisis, which is a well documented phenomenon.4 Research from the US has emerged that following surgery the risk of subsequent opioid dependency in opioid naïve patients may be as high as 6.5%5 . Interestingly, the 3 biggest risk factors for subsequent opioid dependence in the US have been identified as the use of modified release opioid preparations eg Oxycontin ®; drugs going onto repeat prescriptions; and the duration of the prescription. 6,7
We therefore advocate that as well as deprescribing, we need to reflect on prescribing habits. Specifically in view of the opioid crisis that is beginning to be appreciated in the UK,8 we need to avoid the use of modified release opioid preparations for acute pain, which is in line with North American and Antipodean recommendations, 9 we need to avoid opioids prescribed for acute pain continuing onto repeat prescriptions and we need to limit the size and duration of our prescriptions.
References
1. Avery AJ, Bell BG. Rationalising medications through deprescribing. BMJ 2019;364 :l570
2. General |Medical Council . Good practice in prescribing and managing medicines and devices (2013). Available from https://www.gmc-uk.org/-/media/documents/prescribing-guidance_pdf-590552...
3. Hermanowski J, Levy N, Mills P, Penfold N. Deprescribing: implications for the anaesthetist. Anaesthesia. 2017 ;72:565-9.
4. Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ 2017;359:j4792
5. Brummett CM, Waljee JF, Goesling J et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504-.
6. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use-United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66:265-9
7. Brat GA, Agniel D, Beam A et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790
8. Curtis HJ, Croker R, Walker AJ, Richards GC, Quinlan J, Goldacre B. Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database study. The Lancet Psychiatry 2018 Dec 20 [Epub ahead of print].
9. Levy N, Mills P. Controlled-release opioids cause harm and should be avoided in the management of post-operative pain in opioid naïve patients. Br J Anaesth. 2018. Doi https://doi.org/10.1016/j.bja.2018.09.005
Competing interests: No competing interests
'Deprescribing' is being encouraged as a money-saving initiative in Health Services and that is how it is discussed in this article. 'Patient choice' and 'discussions' all sound quite coldly rational and clinical.
It is starkly noticeable that the article appears only to touch very briefly upon the huge issues and suffering that patients are experiencing around dependence and safe withdrawal from over-prescribed antidepressants , benzos, opioids etc.... and these very prescribed medicines are the most likely to be included in the polypharmacy 'cocktails' of patient cases being considered for 'deprescribing'.
Despite BMA 'calls for action' 2016 (1) on 'Prescribed drugs associated with dependence and withdrawal' there has been very noticeable inaction and general obfuscation by the Royal College of Psychiatrists and Royal College of General Practitioners - especially around the very wide (and ever-rising) prescribing of antidepressants - which, like benzodiazepines, carry very serious risks including severe withdrawal problems for many patients. The recently published review by Davies and Read (2018) 'A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?' (2) exposes huge issues - which, whilst the research methodology is still being academically 'debated', the fundamental issues for patient safety simply cannot be ignored.
Indeed, the 'experts' - in late 2018 - are confidently advising GPs to prescribe ever more drugs for 'treatment resistant depression' (3). This is extremely alarming to those of us trying to raise awareness of the terrible experiences of patients, as expressed in BMJ rapid responses by myself and others (4).
Professor Dee Mangin's work on 'Legacy Prescribing in Primary Care' is extremely relevant, and especially her comment that
"Legacy prescribing could also be explored as a quality measure incentivizing restraint in a system where there are few, if any, current indicators of the adverse effects of too much medicine" Prof Dee Mangin 2018. (5)
(1) https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p...
(2) https://www.sciencedirect.com/science/article/pii/S0306460318308347
(3) https://www.bmj.com/content/363/bmj.k5354
(4) https://www.bmj.com/content/363/bmj.k5354/rapid-responses
(5) https://rxisk.org/wp-content/uploads/2019/01/2018-Mangin-Legacy.pdf
Competing interests: No competing interests
This article over-complicates a relative simple issue.
Deprescribing is ideally suited to general practice. Some but not all patients are enthusiastic about trying to reduce the number of medications they take.
The golden rules are to take the long term view, arrange review and never stop or reduce the dosage of more than one drug at a time.
Competing interests: No competing interests
Deprescribing medications that are no longer helpful, or may have become harmful, is not only attractive to patients, physicians & payers but also represents good medical practice. On the face of it, it is somewhat disappointing therefore, that the considerable time and expertise required for review seems to lead to such a small reduction in the tablet count. Figures presented suggest that for 5 patients taking a total of almost 40 medications, a skilled doctor would take 2.5 hours to consider the issues, and having done that would typically deprescribe only one of those medications.
Perhaps we should instead be encouraged that we seem to prescribe drugs that are indicated and needed. So, for a patient with multiple morbidities, polypharmacy may reflect better medical practice than adopting the notion that the fewer drugs a patient is on, the better.
Competing interests: No competing interests
The pessimistic claim “based on reasonably substantive evidence so far, it is unlikely that we are going to see major breakthroughs in deprescribing” deserves comment.(1)
Firstly, medication reconciliation is a long and bumpy road and finding a prudent middle ground to protect patient interests represents an immense tension. Nevertheless, the inappropriate polypharmacy in older people challenges common sense as this population derives not only less benefit from medications, due to multiple pathologies and limited life expectancy, but also more risk of medication-related harms. Worse, among 15 tools for deprescribing in the eldest only four have been tested in clinical conditions, all with very low-quality studies.(2) However, a simple tool is available for an easy beginning, the cornerstone for further success: the yearly list of “drugs to avoid” published by the independent drug bulletin Prescrire which is based on a rigorous procedure. These are a hundred of drugs with adverse effects that are disproportionate to their benefits or drugs superseded by others with a better harm-benefit balance.(3) This list permits easy persuasion of both the patient and the initial prescriber that the reconciliation is based on robust evidence. Drug regulatory agencies should be concerned by reconciliation too but they are going too fast for approval and too slow for withdrawal from the market.(4)
Secondly, some barriers are obvious (limited time to review medications, poor communication between prescribers or lack of respect of primary care physicians’ role as coordinators …) but cognitive biases cannot be overlooked. The question must not be “should the medication be stopped?” but “should this medication have been prescribed?” Withholding and withdrawing treatments must not be regarded as equivalent. Healthcare professionals widely perceive moral differences between withholding and withdrawing, finding it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold).(5)
Thirdly, deprescribing will remain a Sisyphean task, laboriously repetitive, if practitioners were not trained to prescribe according to Evidence Based Medicine rather than to rely on marketing hypes which are on a free ride.
The case of deprescribing shows evidence that quality improvement, the science of process management, is a challenge that still lies far ahead in the healthcare system!
1 Avery AJ, Bell BG. Rationalising medications through deprescribing. BMJ 2019;364:l570. 2 Thompson W, Lundby C, Graabaek T et al. Tools for deprescribing in frail older persons and those with limited life expectancy: A Systematic Review. J Am Geriatr Soc 2018. Online Oct 13. doi: 10.1111/jgs.15616.
3 Towards better patient care: drugs to avoid in 2018" Prescrire International 2018; 27 (192): 107-1 - 107-9 (Pdf, free) http://english.prescrire.org/en/AA26644A665789B5BD5C3814F73AE19D/Downloa...
4 Braillon A, Menkes DB. Balancing accelerated approval for drugs with accelerated withdrawal. JAMA Intern Med 2016;176:566-7.
5 Wilkinson D, Butcherine E, Savulescu J. Withdrawal aversion and the equivalence test. Am J Bioeth 2018. In press.
Competing interests: No competing interests
Re: Rationalising medications through deprescribing: The challenge of polypharmacy reviews
Tony Avery’s editorial on deprescribing (BMJ 2019;364:l570) highlights the challenges of deprescribing and polypharmacy review, particularly the complexity and consultation time.
A stop, sorted and special approach can help to focus a review. Medicines that that can or should be stopped and those that have already been sorted can generally be quickly identified. This leaves a much smaller group of medicines on which to focus the discussion.
STOP The obvious ones: person doesn’t like them, is not taking them, shouldn’t be ‘on repeat’ or the condition has
resolved
SORTED Medicines assessed and monitored within the last 12 months E.g. chronic disease clinics or hospital review,
and no outstanding concerns
SPECIAL Focus of the discussion: Person’s priorities, high-risk medicines, prescribing indicators (see below).
Many clinicians find a polypharmacy review challenging, however it is likely to be an important opportunity both for patients and for a sustainable NHS. There is no single way to undertake a review and recognising the following components can help clinicians to develop their own approach:
o Identify the common combinations and culprits 1,2,3,4
o Recognise multimorbidity, frailty and a person’s priorities 5,6
o Develop a personalised systematic approach (Scotland & Wales polypharmacy guides, No TEARS 7; Stop, sorted and special)
o Be flexible & prioritise
Focusing consultations in these ways, may help to identify a meaningful intervention
References
1. Pirmohamed M, Adverse drug reactions as cause of admission to hospital BMJ 2004;329:15
2. Stocks S J, Examining variations in prescribing safety in UK general practice BMJ 2015;351:h5501
3. Gallagher P et al., Screening Tool of Older Person's Prescriptions 2008 Int J Clin Pharmacol Ther. 46:72-83
4. Lewis T, Top ten prescribing errors, and how to avoid them Pulse 2015
5. Atul Gawande, Being Mortal
6. NICE NG56 Multimorbidity: clinical assessment and management
7. Lewis T, Using the NO TEARS tool for medication review BMJ 2004; 329:434
Competing interests: Author of: Using the NO TEARS tool for medication review BMJ 2004; 329:434 Top ten prescribing errors, and how to avoid them Pulse 2015