De-prescribing

De-prescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm or no longer provides benefit to the patient. It aims to manage polypharmacy and minimize the potential for adverse drug reactions while optimizing therapeutic outcomes for patients. This process is particularly relevant in the elderly or in patients with multiple comorbidities where the burden of medications can often contribute to a decrease in quality of life, increased risk of falls, confusion, and hospitalization.

In the RACGP KFP both Prescribing and De-Prescribing are considered phamacological management.

Importance of De-prescribing

  • Reduces Polypharmacy Risks:
    • Polypharmacy increases the risk of adverse drug reactions, drug-drug interactions, and medication non-adherence, particularly in older adults.
  • Improves Patient Outcomes:
    • De-prescribing can improve patient outcomes, reduce hospital admissions due to medication side effects, and improve quality of life by reducing unnecessary medications.
  • Cost-effectiveness:
    • Discontinuing medications that are no longer needed can lead to significant cost savings for both patients and healthcare systems.

Considerations for De-prescribing

  1. Patient-Centered Approach:
    • It involves discussing the goals of care with the patient and considering their values, preferences, and quality of life.
  2. Comprehensive Medication Review:
    • This is crucial to identify medications that can be safely de-prescribed, considering factors like drug-disease and drug-drug interactions, duplications, and the patient’s current health status.
  3. Monitoring and Support:
    • Close monitoring for withdrawal effects, recurrence of the underlying condition, and patient support throughout the process are essential.
  4. Collaboration:
    • Involves a team approach among physicians, pharmacists, nurses, and other healthcare professionals to ensure a safe and effective process.

Steps in De-prescribing

  1. Identify Potentially Inappropriate Medications:
    • Use evidence-based criteria (e.g., Beers Criteria, STOPP/START criteria) to identify medications that may be inappropriate.
  2. Assess Medication Necessity:
    • Evaluate each medication for its current relevance to the patient’s clinical condition.
  3. Plan De-prescribing:
    • Develop a plan for tapering or stopping the medication, considering potential withdrawal symptoms and the need for monitoring.
  4. Implement the Plan:
    • Communicate clearly with the patient and their caregivers about the plan, including the rationale for de-prescribing and what to expect.
  5. Monitor and Adjust:
    • Closely monitor the patient for withdrawal effects or recurrence of the condition the medication was treating, and adjust the plan as needed.

Challenges and Barriers

  • Fear of Withdrawal or Condition Recurrence:
    • Patients and providers may be concerned about the potential return of the medical condition being treated.
  • Lack of Guidelines:
    • For some medications or conditions, clear guidelines on how to safely de-prescribe are lacking.
  • Communication and Coordination:
    • It requires effective communication and coordination between the healthcare team and the patient.

De-prescribing is an integral part of good prescribing practice and patient care. It aims to maintain or improve quality of life through medication optimization. To ensure its success and safeguard patient health, it requires careful planning, monitoring, and a collaborative approach.

STOPP/START

  • STOPP (Screening Tool of Older Persons’ Prescriptions)
  • START (Screening Tool to Alert to Right Treatment)

STOPP/START are complementary tools designed to optimize medication use in older adults, particularly those with polypharmacy (the use of multiple medications). Developed to improve prescribing practices, these tools aim to reduce the incidence of adverse drug reactions, enhance patient outcomes, and promote the use of beneficial medications often under-prescribed in the elderly.

STOPP Criteria

The STOPP criteria list potentially inappropriate medications (PIMs) that should generally be avoided in older adults, or that should be used with caution under specific conditions. The criteria are organized by physiological systems for easier reference, including the cardiovascular, central nervous system, gastrointestinal, and renal systems among others. Examples of STOPP criteria include:

  • Tricyclic antidepressants in patients with a history of falls or fractures, due to their sedative and orthostatic hypotension effects.
  • Benzodiazepines in older adults with a history of falls, given their impact on cognitive function and balance.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) in individuals with a history of peptic ulcer disease or chronic kidney disease, due to the increased risk of exacerbation.

START Criteria

Conversely, the START criteria identify instances where medications are likely to provide significant benefits but are underused in the elderly population. START focuses on ensuring that older adults receive medications indicated for their conditions in order to improve their quality of life and prevent complications. Examples include:

  • Statin therapy in patients with documented cardiovascular disease to reduce the risk of further cardiovascular events.
  • Osteoporosis treatment in patients with known osteoporosis or previous fragility fractures to reduce the risk of additional fractures.
  • Anticoagulation in patients with atrial fibrillation to prevent thromboembolic events.

Application in Clinical Practice

The STOPP/START criteria serve as a practical guide for clinicians, pharmacists, and healthcare providers involved in the care of older adults. They are used in various settings, including primary care, hospital admissions, and long-term care facilities, to review and manage patients’ medication regimens. The application of these criteria involves:

  1. Reviewing Current Medications:
    • Assessing each medication a patient is taking against the STOPP criteria to identify any PIMs and consider alternatives or adjustments as necessary.
  2. Identifying Omissions:
    • Using the START criteria to ensure that patients are receiving all the medications indicated for their conditions.
  3. Collaborative Approach:
    • Involving a multidisciplinary team, including doctors, pharmacists, and nurses, to discuss and implement changes in the medication regimen.
  4. Patient Engagement:
    • Discuss potential changes with patients, consider their preferences, and educate them on the reasons for any alterations to their prescriptions.

Benefits and Limitations

The implementation of STOPP/START can lead to improved medication safety, reduced adverse drug events, and enhanced patient outcomes. However, its effectiveness depends on regular medication reviews and updates to the criteria based on current evidence and clinical guidelines. While STOPP/START provides a structured approach to medication review, it does not replace clinical judgment. Healthcare providers must consider individual patient factors, including comorbidities, preferences, and life expectancy, when applying these criteria.