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Medication Deprescribing 5/7/2020 Medication Deprescribing: Medication discontinuation, dose reduction, and switching in the PPD Promise™ hospice setting Quarterly In-Services Presented by: Corina Reyna, PharmD, BCGP Co-Founder/Head Clinical Hospice Pharmacist Origins Pharmacy Solutions® Eagle, Idaho Graduate of Idaho State University College of Pharmacy benefits manager (PBM) for hospice agencies Pharmacy Idaho based company providing services 15 years of hospice pharmacy experience nationwide ◦ Compounding Advocate for hospice in the pharmacy setting Minimizing medication costs ◦ Medication therapy reviews Optimizing medication therapy through medication ◦ Speaker at state hospice conferences throughout reviews and streamlined reporting services the Northwest PPD Promise™ Partner with hospice to meet hospice’s medication PPD Board Certified Geriatric Pharmacist (BCGP) goal ® Origins’ pricing model, reporting, service options, and Co-founder of Origins Pharmacy Solutions hospice coaching combine to lower PPD by $3, on average Built on premise of giving back to communities Presenter Background 1) Upon completion of this session, participants will be able to describe the pitfalls of polypharmacy and why Target deprescribing is valuable in the hospice Audience population. •Nurses 2) Attendees will leave with the ability to list three barriers to depresribing and how to •Medical providers address them. •Administrators 3) Participants will leave the session able to describe key points important in conversations about deprescribing. Objectives 1 5/7/2020 Polypharmacy One study estimates hospice patients come on ◦ Can be defined several ways: services on an average of 11.5 medications. Oxford Dictionary: the simultaneous use of multiple drugs to treat a single ailment or condition. U.S. Pharmacist Journal: the use of several (usually five or more) medications on a daily basis, with the possibility that these may not all be clinically necessary. Drug Utilization Review Teams: the use of more medications than are clinically indicated. Polypharmacy Polypharmacy US Pharm. 2017;42(6):13-14. https://www.express-scripts.com/art/pdf/kap37Medications.pdf McNeil, et.al. The burden of polypharmacy in patients near the end of life. J. Pain Symptom Manage. 2016 Feb;51(s):178-183. Polypharmacy increases risks: According to www.deprescribing.org: ◦ Drug interactions ◦ “The planned and supervised process of dose ◦ Adverse effects reduction or stopping of medication that might be ◦ Pill burden causing harm, or no longer be of benefit. Of particular concern if difficulty swallowing Deprescribing is part of good prescribing – backing Higher rate of non-compliance off when doses are too high, or stopping Hospice population more likely to medications that are no longer needed.” experience problems associated with According to palliative care educator: polypharmacy ◦ “The process of identifying and discontinuing ◦ Hepatic and/or renal impairment medications with little or no benefit and potential harm, in order to improve quality of life.” ◦ Altered protein binding due to decreased nutritional status Dangers of polypharmacy What is deprescribing? Deprescribing.org. Retrieved from https://deprescribing.org/what-is-deprescribing. Accessed 3/4/2020 Thompson, J. Deprescribing in palliative care. Clinical Medicine. 2019;19(4):311-4 Medication costs ◦ Why pay for medications that are no longer When used appropriately, providing benefit and/or putting patient at risk? Patient’s goals of care might not align with deprescribing is ensuring medication therapy in place at admission the continuation of Minimize risk of adverse effects ◦ Potentially increasing QoL compassionate comfort Minimize drug interactions Decrease pill burden care. Allow for switch to more appropriate product or route of administration Why consider deprescribing? What else is deprescribing? 2 5/7/2020 Discontinuation of unnecessary or Changes in goals of care inappropriate medications in the hospice Anticipated decline in overall patient status setting Impairment resulting from contributing Decreases in dosing of medications to diagnoses compensate for declines in clearance and Risk vs. benefit changes at end of life metabolism or to minimize risk of Desire for maximal quality of life undesirable adverse effects Satisfy CMS expectations Switching medications in order to optimize symptom control and minimized ◦ Medications expected to help meet goals of care or enhance comfort, therefore palliative in nature. cost and adverse effects What might deprescribing include? Why consider deprescribing? Considerations Questions to ask about each current medication Provide relief from active symptoms of Indication Is it still indicated? disease Risk vs. benefit Does its benefit outweigh its associated risks? Provide comfort Appropriateness Is use appropriate in light of age, co-morbidities, goals, etc.? Not for the use of prolonging life Dosing Is dosing appropriate for age, co-morbidities, and indication? Adherence How is patient taking it? Is this as prescribed? Not curative Duration of use Is the medication no longer beneficial? CMS expects coverage under the hospice Life expectancy Is benefit unlikely to be realized given life expectancy? benefit of medications that are reasonable Adverse effects Is patient experiencing undesireable adverse effects? and necessary for the palliation of pain Patient's desires Does patient want to continue or stop it? and/or symptom management. Patient’s goals of care Does treatment goal align with patient’s goals of care? Discontinuation of medications not helping Prescription cascade Is it treating adverse effects of another medication? patient/family meet goals of care or enhance comfort Considerations in presence of polypharmacy Palliative Medications Update on Part D Payment Responsibility for Drugs for Beneficiaries Enrolled in Medicare Hospice, November 15, 2016 Many barriers to deprescribing: Abundance of guidelines on adding ◦ Psychologic connection to drug Patient, family, and/or provider medications: Fear of withdrawal effects or return of symptoms ◦ American Diabetic Association: diabetes ◦ Lack of patient/family understanding of prognosis guidelines ◦ Consumer advertising ◦ Lack of clear evidence in literature ◦ JNC 8 and ACC/AHA: STEMI guidelines ◦ Limited time with patient ◦ CHEST: VTE guidelines ◦ Lack of palliative care knowledge by prescriber ◦ AACE/ACE: osteoporosis guidelines ◦ Lack of clinician confidence Low knowledge of palliative care ◦ GOLD: COPD guidelines Fear of worsening patient’s symptoms ◦ APA: Depression guidelines Fear of causing patient psychological distress Fear of clinician’s liability Why can deprescribing be so Why can deprescribing be so difficult? difficult? 3 5/7/2020 What are the Hospice Deprescribing Guidelines? OncPal Deprescribing Guidelines: ◦ Helps identify potentially inappropriate medications in palliative cancer patients ◦ Results correspond strongly with analysis of expert panel ◦ Obstacles to use: Desprescribing organization in Canada Applied to palliative cancer patients only ◦ Various resources, including deprescribing Still requires prescriber analysis of patient history algorithms for: Does not take into consideration individual patient PPIs goals of care Cholinesterase inhibitors and memantine ◦ Provides good starting point for considerations Antihyperglycemics in deprescribing Deprescribing Guidelines Deprescribing Guidelines Lindsay, et.al. The development and evaluation of an oncological palliative care deprescribing guideline: the 'OncPal deprescribing guideline'. Support Care Cancer. July 2014. https://www.mascc.org/assets/Pain_Center/2014_July/july_2014- 2.pdf https://deprescribing.org/resources/deprescribing-guidelines-algorithms Lack short-term benefit (long time-to-benefit): Some of the best evidence to support discontinuation for certain ◦ Statins patients in the hospice setting ◦ Antihypertensives Kutner, et al. study can be directly applied to the hospice setting: ◦ Inclusion: ◦ Proton pump inhibitors (PPIs) Adults with an estimated life expectancy of 1 month to 1 year ◦ Oral hypoglycemics (possibly) Recent deterioration in functional status Statin therapy for at least 3 months for primary or secondary prevention of Otherwise preventative in nature cardiovascular disease ◦ Prophylactic antibiotics No recent active cardiovascular disease ◦ Antithrombotics ◦ Intervention: Statin was withdrawn for patients randomized to the discontinuation group No longer beneficial for certain populations ◦ Enrollment: 381 patients; mean age of 74.1 years; 22% were cognitively ◦ AChE inhibitors, i.e. donepezil (Aricept®), galantamine impaired; 48.8% had cancer (Razadyne®), rivastigmine (Exelon®), ◦ Results: ® No significant difference in rate of death within 60 days between the ◦ Memantine (Namenda ) two groups Vitamins/minerals/herbs Overall quality of life (QoL) was found to be better for the discontinuation group ◦ Not likely to provide benefit unless treating confirmed low serum concentrations or patient history indicates significant improvement in QoL with use What medication classes most Deprescribing Considerations: likely need addressed? Statins Kutner, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA. 2015 May;175(5):691-700 https://www.ncbi.nlm.nih.gov/pubmed/25798575 4 5/7/2020 Consider discontinuation of statins when: Reason for discontinuation: ◦ No recent
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