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Deprescribing requires vigilance

In my last blog I wrote about the little used practice of deprescribing and the benefits that accrue to patients and payers. As I was searching for my next blog topic I ran across an interesting study in the Journal of Managed Care and Specialty Pharmacy (JMCP) that focused on…wait for it…deprescribing. And it’s a nice corollary to my last blog, so I thought I would review that article for you here.

In my last blog, we reviewed the goals (reducing polypharmacy, anticholinergic load, etc) and the process (iterative) for deprescribing efforts. In the April 2020 edition of JMCP Martinez, et. al. published an article – One-Year Evaluation of a Targeted Medication Therapy Management Intervention for Older Adults – which focused on understanding the sustainability of deprescribing effort (1 year post intervention).

The Martinez study reviewed a randomized control trial of deprescribing conducted over an 8-week period. Patients in both groups were drawn from participants in a longitudinal study at the University of Kentucky Alzheimer’s Disease Center (UKADC). Patients were eligible for the anticholinergic deprescribing trial if they were 65 years and older and had at least 1 anticholinergic medication in their medication regimen at their annual UKADC visit. Patients living in long-term care facilities or who had been diagnosed with moderate or severe dementia (based on the CDR Dementia Staging Instrument score ≥ 2) were excluded.

Patients who met the inclusion/exclusion criteria were randomly assigned to either the medication management (MM) intervention or standard care (SC) group. After randomization, 1,937 patients were included in the study. The intervention and control groups were similar with regard to demographic characteristics. The mean age of the study participants was 76.9 years). Females composed 64.8% of the study population. The study population was predominantly white race (83.8%), and had 15.9 years of education. Both groups had a similar proportion of patients with impaired cognition. The intervention group did exhibit more medications and higher anticholinergic burden at baseline than their control counterparts.

Each patient regardless of group was provided with informational material regarding the importance of actively understanding and reviewing their medication regimens. The informational piece encouraged participants in the trial to speak with their primary care providers about their medications.

The deprescribing intervention consisted of patients meeting with a pharmacist-provider (physician or mid-level) team. The objective of the meeting was to discontinue potentially inappropriate medications with anticholinergic properties or replace anticholinergic agents with safer alternatives (i.e., deprescribing). When discontinuation of the anticholinergic was inappropriate, the clinician team sought to reduce the dose to the minimally necessary dose. Due to ethical considerations the patients in the control group received a “light” version of the MM intervention at the end of the RCT in which their medication regimens were reviewed and the clinician team provided recommendations regarding anticholinergic medication use.

Intervention analysis focused on two primary endpoints:

  • Change in antichgolinergic use as measured specifically by –  patterns of anticholinergic medications use, mean change in anticholinergic burden, and odds of decreasing use of anticholinergic medications
  • Sustainability of change

Analysis found that patients in the MM intervention group had a decrease in anticholinergic antihistamines and bladder agents (−6.5 and −4.4%, respectively), but there was no change in the use of anticholinergic agents targeted at the central nervous system. Additionally, the anticholinergic burden of the intervention group participants decreased over 1 year (adjusted mean ADS change [95% CI] = −0.33 [−0.72, 0.07]), however it was not different than the change observed in control group (−0.20 [−0.42, 0.02]). Consequently, the study found that there were no statistically significant differences in the odds of decreasing anticholinergic burden (between trial and control participants) nor in decreasing the number of total, or strongly anticholinergic, medications at the 1-year follow-up. Of the deprescribing changes made during the initial RCT, 50% were sustained after 1 year.

For us at CSS, this study confirms one of the assertions that we made in our last blog. Specifically that the design of a deprescribing initiative must be iterative – Performing deprescribing is best when approached in an iterative fashion reducing medicines or doses one at a time.

In addition, this study informs a component of deprescribing MM that we had not previously considered – vigilance. This study demonstrates that there is a significant amount of recidivism at least with regard to the sustainability of anticholinergic deprescribing. This indicates that design of a MM deprescribing effort should include a periodic reassessment post deprescribing to assure that offending drugs are not reintroduced back into the patient’s medication regimen.

As always, I am happy to discuss how you might incorporate the CSS Health Deprescribing Companion Program into your medication management efforts.

Best – Jim
Jim Notaro, RPh, PhD
Founder and Chief Clinical Officer

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