Deprescribing is the cure for ‘disease’ of polypharmacy

Tools abound for assessing polypharmacy

Prescription drug use is rising in the United States, outpacing population growth. According to a nationwide survey published in Consumer Reports in August 2017, the number of prescriptions increased 85% over 20 years, while the population grew by 21%. Some of the increase stems from polypharmacy as 77 million baby boomers reach their 70s. A study by Qato and colleagues published in the April 2016 JAMA Internal Medicine found that among adults with a mean age of roughly 71 years, 35.8% take at least five prescription medications, and 67.1% take five or more medications or supplements of any kind, including OTC medications.

Polypharmacy of that magnitude carries so great a risk for negative outcomes in older adults that it should be seen as a disease, said Andrew Whitman, PharmD, clinical pharmacist in oncology and palliative care at University of Virginia Health System in Charlottesville. 

“If you break down polypharmacy as you would a typical disease, it has the same elements. It comes with risk factors like chronic disease states, polymorbidity, transitions of care, and seeing a number of different prescribers,” Whitman said. “It also has symptoms or consequences, like nonadherence of other essential medications, cognitive impairment, falls, pill burden, and personal and health care financial toxicity. Finally, it can have exacerbating factors, including prescribing cascades, lack of communication among providers, and lack of education for patients.”

The cure, then, is deprescribing, Whitman said.

“Deprescribing should always be part of the good prescribing continuum. I tell all of my patients that most of their medications have a ‘do not use beyond’ date when the medication may no longer be needed or have a different impact on their body as they age,” Whitman said. 

Tools abound for assessing polypharmacy, with the Beers Criteria setting the standard. But in a pilot study Whitman and his colleagues published in the December 2018 Supportive Care in Cancer suggests that the Beers Criteria alone may not be enough. 

In the study, the researchers collected data for 26 patients with cancer who were at least 65 years old and were taking a mean of 12 medications. When they used only the Beers Criteria, they identified 38 potentially inappropriate medications, but when they also used the Screening Tool of Older Persons’ Prescriptions (STOPP) and the Medication Appropriateness Index (MAI), they identified 119 potentially inappropriate medications. After assessment with all three screening tools, 73% of potentially inappropriate medications were deprescribed (roughly three medications per patient), and approximately two-thirds of patients said they had fewer symptoms after the deprescribing. Whitman and his team estimated that deprescribing potentially avoided $4,282.27 in health care costs per patient.

“I believe the important part of this process is the combination of implicit and explicit screening tools,” Whitman said. “The Beers Criteria and STOPP are quick tools to flag specific medications or medication classes, and the MAI helps to clinically evaluate the remaining medications for things like whether the medication is effective for the condition and the most cost-effective, and whether the directions are practical.”

That the study population had cancer should not deter pharmacists in all practice settings from using multiple tools to assess for polypharmacy, Whitman added. 

“[Assessment and deprescribing] in our setting are pretty similar to that of the general population. The main difference is that our patients are exposed to anticancer therapies that add a layer of complexity to the equation.”

L. Hayley Burgess, PharmD, BCPP, CPPS, associate vice president of clinical pharmacy and medication safety in the Clinical Services Group at HCA Healthcare in Nashville, said that hospital pharmacists and other clinicians should collect and evaluate patients' use of home medications.

“With OTC medications like proton pump inhibitors or histamine-2 blockers, we tend to believe patients started the medication for a therapeutic reason, and we don’t do a deep dive for why, but we need to consider whether it needs to be continued,” Burgess said. 

Community pharmacists have the greatest advantage in discussing deprescribing with patients, Burgess said. 

“They may have long-term relationships with patients. They know their patients and interact with them often. The access allows the conversation, ‘Mrs. Smith, why were you taking this medication? Do those issues remain? Did you know that these medications may cause harmful is-sues over time?’” Burgess said. “Community pharmacists are trusted, and they have relationships with the physicians and can empower patients for a discussion with their prescribers.”

For the full article, please visit www.pharmacytoday.org for the December 2018 issue of Pharmacy Today.