+                                                   VI jornadas                                                   uso adec...
+      what   is “deprescribing”?      how   to deprescribe?      what´re   the basis?      how   to desprescribe? who...
+
+      discontinuation      drug removal / cessation      drugectomy      from polypharmacy to    oligopharmacy
+              cut off    pruning             logging
+    extirpation
+                gotic deco    minimalism
+    How? Fernandez did not    come to work because    he´s been buried? Well, I    hope he do not forget to    bring a ce...
+    diagnosing     indicating    prescribing     supplying    following up    deprescribing                    therapeuti...
+    prescribing   deprescribing
+      process of adaptation of drug     regimen: tappering, replacing,     eliminating drugs      must take in consider...
+
+    1.    review, review and again review    2.    reconsider therapeutic plan    3.    taper off, eliminate, substitute ...
+      review   complete list of drugs        be careful with over the counter drugs,        naturopathics, non solid dr...
+    Holmes H, et al. Arch Intern Med. 2006;166:605-9
+      reviewthe indication (active?, goals?,     time to benefit?)      analize   the compliance degree      detect   ...
+      no   longer used drugs      drugs   for inactive or cured diseases      those   that caused adverse effects    ...
+      Beers      criteria    Examples:    -  digoxin,    0,25 mg/d, in heart failure    -  amitriptiline                ...
+      STOPP-START               criteria    Examples:    -  thiazides    if history of gout    -  NSAID  if uncontrolled...
+    Maddison AR, et al. Prog Palliat Care. 2011;19:15-21
+      explaining    and involving      talking,   informing, and, above all,     listening      preferences,    expect...
+      enhancing    therapeutic adherence      highlighting   achievements      supporting      detecting   recurrence...
+
+      inappropriate                   polypharmacy as a public     health problem      absence     of scientific eviden...
+  40%    of institutionalized & 25% of outpatient    elderly has at least one inappropriate drug  20%      >70 years us...
+    Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31
+    N = 339. Age > 80 y    Jyrkkä et al. Drugs Aging. 2009; 26:1039-48
+                  are there                 evidences?    what tells        the     studies?     and the    guidelines   ...
+
Lee PY, et al. JAMA. 2001;286:708-13
patients included in clinical trials%                                 general population with dementia302010     60-64   6...
+
+                                       RR = 0.82 (0.69-0.99)                                       NNT = 46 (637- 24)    ...
+                                            •  dependence personal                                            hygiene: 1 ...
+    •  congestive heart failure requiring treatment with    a diuretic or ACO inhibitors    •  renal failure (serum creat...
+    Van Bemmel T, et al. J Hypertens. 2006;24:287-92
+    Iyer S, et al. Drugs Aging. 2008;25:1021-31
+    Walma EP, et al. BMJ 1997;315:464–8
+       N = 5804, 70-82 yShepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7
+     The fallacy of cheating death has    been promulgated by the apostles of    altered life-stile. In their enthusiasm,...
+    Hello, guy! How well youve come!
+      ifit occurs in young patients: fast death,     without suffering      in the elderly: a natural dying, “a good wa...
+    •  ibandronate, etidronate    no studies in this age group     alendronate    only one trial that includes >80 y wome...
+    RR = 0.6 (0.4–0.9), p = 0.009        RR = 0.8 (0.6–1.2), p = 0.35                 McClung MR, et al. NEJM 2001;344:33...
+     application of NOF guidelines to general population     estimated that at least 34% of US white men aged       65 ye...
+    Black DM, et al. JAMA. 2006;296:2927-38
+    Lai SW, et al. Medicine.        2010;89:295-99
+                                                                  Information                              Information In...
+        hypothetic patient. 79 years, hypertension, COPD, type 2         diabetes, osteoporosis and osteoarthritis (all ...
+    Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52
+      terminal patients: symptoms and personal care      (no pain, no anxiety, no dyspnea, personal      hygiene), prepa...
+
+      givena particular patient, reconsider     the therapeutic regimen, deprescribing     the unnecessary drugs      po...
+      do   the benefits outweigh the risks?      exceeds the life expectancy of this     patient the drug time to benef...
+Garfinkel D, Mangin D. Arch        Intern Med.     2010;170:1648-54
+      given           a particular inappropriate drug,     review every patient that uses it and act               more ...
+
+      two kind of patients: terminally ill and     fragile elderly      more   accepted and usual in terminally ill
+
+      outside             agent: greater objetivity,     worse actual knowledge about patient´s     environment      be...
+
+        drugs reduction (mean 0.5-2.8/patient)        hospital referals, less than control group (12% Vs 30%)        m...
+
+    Hardy JE, Hilmer SH. J Pharm Pract Res. 2011;41:146-51
+    In the end I didnt know what was worse,    um, having the … withdrawal effects from it    or having the, um … depress...
+      tapper    or discontinue gradually      betterin those with few drugs for a     specific process      close    f...
+
+    health system        e-prescribing        aggresive guidelines        induced prescribing    physician barriers   ...
+     physician-patient relationship             not addressing deprescribing with patient / family             not cons...
+
+      ageism      paternalismor assymetry in decision     making (i decide, then i inform you)      forgetting        ...
+
+        firstly, non-pharmacological approach     seeking the causes of the causes (fundamental    causes)        wait...
+        anticipate possible adverse effects        unbiased sources of information and learning        enhance adheren...
It is an art of no little importance toadminister medicines properly: but, it is an  art of much greater and more difficul...
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Learning to Deprescribe Drugs, english version

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    Has is change prescribers' deprescribing habits?
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  • Great presentation and great topic. Can you tell me to whom you gave the talk and how it was received?
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Transcript of "Learning to Deprescribe Drugs, english version"

  1. 1. + VI jornadas uso adecuado medicamentos Plasencia 3 nov 2011 enrique gavilán general practitioner research department polypharmacy laboratory www.polimedicado.com / enrique.gavilan@yahoo.es
  2. 2. +   what is “deprescribing”?   how to deprescribe?   what´re the basis?   how to desprescribe? who? by whom?   does it works?   what´re the risk / barriers / threats?
  3. 3. +
  4. 4. +   discontinuation   drug removal / cessation   drugectomy   from polypharmacy to oligopharmacy
  5. 5. + cut off pruning logging
  6. 6. + extirpation
  7. 7. + gotic deco minimalism
  8. 8. + How? Fernandez did not come to work because he´s been buried? Well, I hope he do not forget to bring a certificate! therapeutic retirement
  9. 9. + diagnosing indicating prescribing supplying following up deprescribing therapeutic chain
  10. 10. + prescribing deprescribing
  11. 11. +   process of adaptation of drug regimen: tappering, replacing, eliminating drugs   must take in consideration the scientific evidence, social and physical function, comorbidity, quality of life and patient´s preferences
  12. 12. +
  13. 13. + 1.  review, review and again review 2.  reconsider therapeutic plan 3.  taper off, eliminate, substitute 4.  agree with the patient / caregiver 5.  follow upHardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51. Bain KT, et al. JAGS. 2008;56:1946-52. Woodward MC. J Pharm Pract Research. 2003;33:323-8.
  14. 14. +   review complete list of drugs   be careful with over the counter drugs, naturopathics, non solid drugs   medication reconciliation in medical transitions   poor congruence with patient (58%) Bikosky RM et al. JAGS. 2001;49:1353-7
  15. 15. + Holmes H, et al. Arch Intern Med. 2006;166:605-9
  16. 16. +   reviewthe indication (active?, goals?, time to benefit?)   analize the compliance degree   detect adverse effects (present and risk)   detectdrug-drug and drug-disease interactionsHardy JE, Hilmer SH. J Pharm Pract Research. 2011;41:146-51
  17. 17. +   no longer used drugs   drugs for inactive or cured diseases   those that caused adverse effects  those that pottentially would cause relevant harms   vicious drug waterfalls Woodward MC. J Pharm Pract Research. 2003;33:323-8
  18. 18. +   Beers criteria Examples: -  digoxin, 0,25 mg/d, in heart failure -  amitriptiline –anticholinergic and sedative properties- -  long life benzodiazepines –fall risk and sedation- Fick DM, et al. Arch Intern Med. 2003;163:2716-24
  19. 19. +   STOPP-START criteria Examples: -  thiazides if history of gout -  NSAID if uncontrolled HBP, renal failure or gastric bleeding -  bladder antimuscarinics if history of dementia or glaucoma Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46:72-83
  20. 20. + Maddison AR, et al. Prog Palliat Care. 2011;19:15-21
  21. 21. +   explaining and involving   talking, informing, and, above all, listening   preferences, expectations, beliefs   adapt rythm to real posibilities
  22. 22. +   enhancing therapeutic adherence   highlighting achievements   supporting   detecting recurrence or worsening symptoms
  23. 23. +
  24. 24. +   inappropriate polypharmacy as a public health problem   absence of scientific evidence for certain drugs   ethics criteria   patient´s preferences
  25. 25. +  40% of institutionalized & 25% of outpatient elderly has at least one inappropriate drug  20% >70 years use 5 or more drugs  difficult adherence, adverse effects, interactions, falls, morbidity, hospital admissions… Wilcox SM, et al. JAMA. 1994;272:292-6. Rollason V, Vot N. Drugs Aging. 2003;20:817-32
  26. 26. + Fulton MM, Allen ER. J Am Acad Nurse Pract. 2005;17:123-31
  27. 27. + N = 339. Age > 80 y Jyrkkä et al. Drugs Aging. 2009; 26:1039-48
  28. 28. + are there evidences? what tells the studies? and the guidelines ? are there elderly in clinical studies?
  29. 29. +
  30. 30. Lee PY, et al. JAMA. 2001;286:708-13
  31. 31. patients included in clinical trials% general population with dementia302010 60-64 65-69 70-74 75-79 80-84 85-89 90-94 age (years) Schoenmaker N, Van Gool WA. Lancet Neurol. 2004;3:627-30
  32. 32. +
  33. 33. + RR = 0.82 (0.69-0.99) NNT = 46 (637- 24) HYVET Study. Beckett NS, et al. NEJM. 2008;358:1887-98
  34. 34. + •  dependence personal hygiene: 1 point •  dependence in dressing: 1-3 points •  malignant disease: 2 points •  congestive heart failure: 3 points •  COPD: 1 point •  renal failure: 3 points Carey EC, et al. JAGS. 2008; 56:68–75
  35. 35. + •  congestive heart failure requiring treatment with a diuretic or ACO inhibitors •  renal failure (serum creatinine > 150 µmol/l) •  condition expected to severely limit survival, e.g. terminal illness •  clinical diagnosis of dementia •  resident in a nursing home (dependence) •  unable to stand up or walk … clinicaltrials.gov/
  36. 36. + Van Bemmel T, et al. J Hypertens. 2006;24:287-92
  37. 37. + Iyer S, et al. Drugs Aging. 2008;25:1021-31
  38. 38. + Walma EP, et al. BMJ 1997;315:464–8
  39. 39. + N = 5804, 70-82 yShepherd J, et al. Lancet. 2002;360:1623–30. Mangin D, et al. BMJ. 2007;335:285-7
  40. 40. + The fallacy of cheating death has been promulgated by the apostles of altered life-stile. In their enthusiasm, they have failed to stress that escaping death from myocardial infarction allows the possibility of dying from cancer, stroke or Alzheimer Disease Mc Cormick JS, Skrabanek P. Lancet. 1984;2:1455-6
  41. 41. + Hello, guy! How well youve come!
  42. 42. +   ifit occurs in young patients: fast death, without suffering   in the elderly: a natural dying, “a good way of dying" Emslie C, et al. Coronary Health Care. 2001;5:25-32 Mangin D, et al. BMJ. 2007;335:285-7
  43. 43. + •  ibandronate, etidronate no studies in this age group alendronate only one trial that includes >80 y women: RRR non vertebral fractures 46% (not as end point) (Pols 1999) •  risedronate -  secondary prevention: RRR in morphologic vertebral fractures 81%, no effect on non-vertebral (Boonen 2004) - low risk primary prevent.: no effect hip fracture (McClung 2001) •  zoledronate - secondary prevention, 55% >75 y: RRR any new fracture 5%, no effect on hip fracture (Lyles 2007) - primary prevention, 37% > 75 y: RRR morphologic vertebral fractures 70%, 41% on hip fracture (Black 2007)Inderjeeth CA. Bone. 2009;44:744-51. Parikh S. J Am Geriatr Soc. 2009;57:327–34. Chua WM. Ther Adv Chonic Dis. 20011;2:279-86
  44. 44. + RR = 0.6 (0.4–0.9), p = 0.009 RR = 0.8 (0.6–1.2), p = 0.35 McClung MR, et al. NEJM 2001;344:333–40
  45. 45. + application of NOF guidelines to general population estimated that at least 34% of US white men aged 65 years and older and 49% of those aged 75 years and older would be recommended for drug treatment Donaldson MG, et al. J Bone Mineral Res. 2010;25:1506–11
  46. 46. + Black DM, et al. JAMA. 2006;296:2927-38
  47. 47. + Lai SW, et al. Medicine. 2010;89:295-99
  48. 48. + Information Information Information about elderly about elderly about multiple with multipledisease patients? comorbidity? comorbidity? diabetes mellitus Yes Yes Yes hypertension Yes No No osteoartrhitis Yes Yes Yes osteoporosis No No No COPD No No No atrial fibrilation Yes Yes Yes congestive heart failure Yes Yes No angina Yes Yes Yes hypercholesterolemia Yes Yes No Boyd CM, et al. JAMA. 2005; 294:716-24
  49. 49. +   hypothetic patient. 79 years, hypertension, COPD, type 2 diabetes, osteoporosis and osteoarthritis (all moderate) Boyd CM, et al. JAMA. 2005; 294:716-24
  50. 50. + Le Couteur DG, et al. J Pharm Pract Res. 2010; 40: 148-52
  51. 51. +   terminal patients: symptoms and personal care (no pain, no anxiety, no dyspnea, personal hygiene), preparation for death, stay mentally alert   elderly: willingness to take preventive medications is very unsensitive to benefits but high sensitive to adverse effects  reducing drugs do not solve all problems and concerns of the elderly ...Steinhauser KE. JAMA. 2000; 284:2476-82. Fried TR. Arch Intern Med. 2011;171(10):923-8. Moen J. Patient Educ Couns. 2009;74:135-41
  52. 52. +
  53. 53. +   givena particular patient, reconsider the therapeutic regimen, deprescribing the unnecessary drugs poda more individualizing time consuming
  54. 54. +   do the benefits outweigh the risks?   exceeds the life expectancy of this patient the drug time to benefit?   isit a logical piece in the current treatment regimen? Compare the indications for the drug and the goals of this patient care
  55. 55. +Garfinkel D, Mangin D. Arch Intern Med. 2010;170:1648-54
  56. 56. +   given a particular inappropriate drug, review every patient that uses it and act more tala feasible less flexible
  57. 57. +
  58. 58. +   two kind of patients: terminally ill and fragile elderly   more accepted and usual in terminally ill
  59. 59. +
  60. 60. +   outside agent: greater objetivity, worse actual knowledge about patient´s environment   bedside health proffesional: greater acceptance (trust, longitudinal attention, accessibility) Moen J. Patient Educ Couns. 2009;74:135-41
  61. 61. +
  62. 62. +   drugs reduction (mean 0.5-2.8/patient)   hospital referals, less than control group (12% Vs 30%)   mortality, less than control group (21% Vs 45%)   no effect on quality of life and mental status   no relevant adverse effects   lower costs: 0,46 $ person/day   limitations: small trials, no good randomization, no blind evaluation, selection bias…Garfinkel D, et al. Isr Med Assoc J. 2007;9:430-4. Garfinkel D, Mangin D. Arch Intern Med. 2010;170:1648-54. Beer C, et al. Ther Adv Drug Safe. 2011;2:37-43
  63. 63. +
  64. 64. + Hardy JE, Hilmer SH. J Pharm Pract Res. 2011;41:146-51
  65. 65. + In the end I didnt know what was worse, um, having the … withdrawal effects from it or having the, um … depression side of it I dont think I take them to sustain my mood but purely just to stop the side effects. Ill maybe be just have to grin and bear it Leydon GM, et al. Fam Pract. 2007;24:570-5
  66. 66. +   tapper or discontinue gradually   betterin those with few drugs for a specific process   close follow up at the beggining   “opened door”   shared decisions   flexibility: any change is irreversible Leydon GM. Fam Pract. 2007;24:570-5
  67. 67. +
  68. 68. + health system   e-prescribing   aggresive guidelines   induced prescribing physician barriers   prescribing, associated to every clinical encounter   overmedicalization and overtherapeutic inertia   we are not programmed to desprescribing   lack of skills to change patient´s attitudes
  69. 69. + physician-patient relationship   not addressing deprescribing with patient / family   not considering patient´s perpective patient   “the time is over” / feeling of surrender   fears, unpleasant past experiencesLeydon GM. Fam Pract. 2007;24:570-5. Hardy JE. J Pharm Pract Res. 2011;41:146-51
  70. 70. +
  71. 71. +   ageism   paternalismor assymetry in decision making (i decide, then i inform you)   forgetting the non-pharmacological aspects (psychological, social and family context, health system performance, expectations, clinical relationship ...) Barsky AJ. Arch Intern Med. 1983;143:1544-8
  72. 72. +
  73. 73. +   firstly, non-pharmacological approach  seeking the causes of the causes (fundamental causes)   wait and see   a few drugs, but well used   the newest is not always the best   changes, one by one   adverse effects, on the jagged edge
  74. 74. +   anticipate possible adverse effects   unbiased sources of information and learning   enhance adherence  patient-centered clinical outcomes rather than surrogate or intermediate markers   remove the needless drugs  promote conservative desires and healthy skepticism in patients Schiff GD, et al. Principles of conservative prescribing. Arch Inter Med. 2011
  75. 75. It is an art of no little importance toadminister medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit themPhilippe Pinel. A treatise on insanity.1806 + Antonio Villafaina Rafa Bravo Sergio Minué Beatriz González Marc Jamoulle … and all of you
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