Hospice Pharmacy Insights April 2021

According to the American College of Cardiology “Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction–a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced.”

Historically hospice clinicians have been very good at deprescribing with the main goal being the highest quality of life for their patients facing the end of life. Recently there has been a surge of research and development in deprescribing in the general health care realm. This has led to the development of protocols and algorithms for the safe deprescribing of drugs in multiple categories. Listed below are some of those drug categories that may be considered for deprescribing.

Identifying medications that are appropriate to deprescribe requires that we consider

1) Benefits no longer outweigh the risks for adverse events.

2) Time to benefit is longer than life expectancy.

3) Treatment target no longer aligns with the patient’s goals of care. Remember deprescribing is a trial… medications can be restarted.

The Easy Discontinuation

• Vitamins, multivitamins, antioxidants
• Supplements
• Bisphosphonates

The Statins

• No difference in 60-day survival rates.
• No difference in cardiovascular events.
• Improved quality of life.

Eye Drops

• If eye pain, redness, or blurriness return restart eye drops.

Antiplatelets/Anticoagulants

• Bleeding risks greater than long-term benefits especially in frail elderly.

Insulins/Antihyperglycemics

• Tight glycemic control can significantly increase the risk of hypoglycemia.
• If needed, consider the cautious use of short-acting insulins.

Antihypertensives

• Goal of B/P <140/90.

PPIs

• Long-term use associated with fractures, C. diff, diarrhea, vitamin, and electrolyte imbalance.

Cholinesterase Inhibitors/Cognitive Enhancers

• Cognitive +/- decline over the past 6 months.
• No noticeable benefit.
• Severe dementia.

Antipsychotics

• Treated for >3 months with symptoms controlled or no response.

Antiepileptics

• AED prophylaxis had no significant preventive effect on seizure incidence or seizure-free survival in patients with brain neoplasms.

This article provided a very brief overview of the categories of medications that may be considered for discontinuation at end of life. We will take a look at each of these categories in more depth over the coming months.