Australian Doctor 4th August 2023 AD 4th Aug Issue | Page 44

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Box 1 . Prescribing cascade example

Figure 1 . It is estimated that more than a third of older Australians , almost one million people , are using five or more medications .

• Prescribing verapamil for hypertension in a very frail person results in severe constipation .

• This problematic side effect may have been predicted , particularly if the person is prone to constipation .

• Treating the constipation with a macrogol and electrolyte preparation creates a feeling of fullness , which causes a loss of an already limited oral intake .

• Decreased intake worsens nutrition and decreased normal fluid intake exacerbates the constipation .

• This significantly impacts quality of life .

• Alternatives include :

— Assess the severity of the hypertension and whether it still needs treatment .

— Choosing an antihypertensive that does not have constipation as an adverse effect .

— Non-pharmacological options such as prunes , which are cheap , tasty and of nutritional value .

When deciding to prescribe medication it is easy to focus on the benefit , but harder to consider the limitations and potential harms . This includes not only the listed side effects but the likelihood of these occurring in the individual given their unique history , physiology , personality , health conditions and concurrent medications . The balance between risk and benefit is often misrepresented or under-considered .

Prescriber factors

Practitioners are healers , with the impulse to do something positive to cure or alleviate . We are not well trained to reassure , wait and see or admit there is nothing chemical with true potential benefit to offer . It takes effort and intellectual rigour to consider non-pharmacological alternatives that may be less harmful or more effective . Practitioners are time poor , so prescribing may be easier .

When a symptom persists despite treatment , another medication may be added without consideration of stopping the initial drug ; substitution rather than addition is a form of not escalating prescribing .

Whenever drugs are represcribed , prescriptions renewed , or medication charts rewritten there is a risk that this is done routinely rather than mindfully .

DEPRESCRIBING

DEPRESCRIBING may be defined as a process of medication withdrawal , supervised by a health practitioner , with the goal of avoiding or managing polypharmacy and improving health outcomes . 7

The term deprescribing has different meanings in different contexts ; patients may view this as ceasing medications and reducing the number of agents they take ; for medical and pharmacy staff it can also mean dose reduction or reduction of total drug burden , plus reducing the number of agents , or cessation of one drug and substitution of a safer or more effective alternative .

Table 1 . Examples of prescribing cascades

Opioid Constipation / nausea Laxative / anti-nausea NSAID Gastric reflux PPI ACEI

Cough Peripheral oedema ( see figure 2 )

Deprescribing needs to be done thoughtfully , with good rationale , collaboratively with the patient , and cautiously and slowly . It should be part of routine good prescribing practice to ensure ongoing safe and effective medication use . 8

Ideally , integrating deprescribing begins when a medication is initiated , with the expected duration of therapy included at the onset as part of the patient instructions . 3 , 8

If ‘ not prescribing ’ is a logical extension of the idea of deprescribing , then it is important to establish at the point of initial prescribing if the medication is addressing a cause or significant risk , or a symptom that might well resolve on its own or be caused by something else . Patients may be amenable to non-pharmacological approaches . Managing expectations when prescribing is important for subsequent deprescribing as this approach establishes

Cough suppressant , diuretic

Macrolide antibiotic Nausea Antiemetic ( eg , metoclopramide ) Antipsychotic Extrapyramidal effects Anticholinergic ( eg , benztropine )

Dihydropyridine calcium channel blocker , eg , amlodipine

Oedema Loop diuretic ( eg , furosemide )

Thiazide

Hyperuricaemia , gout ( see figure 3 )

Urate-lowering agent ( eg , allopurinol )

Beta blocker Dizziness Antiemetic ( eg , prochlorperazine ) Benzodiazepine Memory impairment Cholinesterase inhibitor Source : Kalisch LM et al 2011 9 , Rigby D 2021 10 the expectation of a short time frame and early deprescribing when appropriate . For example , “ This is a trial — if it doesn ’ t help , we will stop it ”, or , “ This medication is recommended only for short-term use , so I am going to give you a short course — this may have side effects that we will review ”.

Deprescribing may , of course , involve a single unwanted or unnecessary medication ; however , it is usually more of a focus where polypharmacy is present .

Prescribing cascades

A prescribing cascade occurs when a new medication is prescribed to treat an adverse reaction to another drug , in the mistaken belief that the adverse effect is a new medical condition requiring treatment . 9 This negative cascade increases the risk of polypharmacy ( see box 1 ).

Medicines commonly implicated

Box 2 . When to consider deprescribing

• When polypharmacy is identified .

• Change in condition or prognosis , or when goals of care change .

• When symptoms or signs emerge that may be medication effects .

• When a person is taking a medication that is : — No longer indicated or justified or with no reason not to stop it . — Causing more harm than good , where the risks outweigh the benefits . — Causing adverse effects that affect quality of life : postural hypotension , constipation , poor appetite , balance / falls , lightheadedness or weight gain . — No longer wanted by the patient . — Expensive .

Box 3 . Patients in high-risk medication situations

• Polypharmacy ( see figure 4 ).

• Multimorbidity .

• Multiple prescribers ( see figure 5 ).

• Transitions of care .

• Renal impairment .

• Non-adherence or sporadic adherence .

• End-of-life setting .

• Dementia or other cognitive impairment .

• Frailty , malnutrition , falls , confusion , drowsiness . Adapted from Steinman M 2021 8

in prescribing cascades include sedatives , opioids , NSAIDs , antiepileptics , antibiotics and antiemetics ( see table 1 ). 9 , 10

When and how to deprescribe

Deprescribing ( see box 2 ) requires attention , time and , in some cases , special skills and knowledge of optimal tapering schedules , plus shared decision-making , communication and experience managing complex health systems . 8 Deprescribing can be an interdisciplinary process which is communicated to all practitioners involved in the patient ’ s care . 11

The process can be facilitated by knowing and addressing potential barriers , using a systematic process and identifying deprescribing opportunities by engaging with patients , caregivers and other health practitioners . 3

Mindful represcribing will identify ongoing opportunities to deprescribe in the normal course of patient care .

Overcoming barriers

Numerous barriers to deprescribing have been identified . 3 , 12-17 Understanding these and applying strategies to overcome them is important in facilitating deprescribing ( see table 2 ). 3

Opportunities for deprescribing

Although most commonly considered in geriatric and end-of-life settings , deprescribing is also appropriate in other patient groups . 7 High-risk medications , agents with dubious benefits , those causing adverse effects and medications requiring a complex regimen are potential targets for deprescribing . 8 , 19 Patients in high-risk medication situations are listed in box 3 .

Consider this a long-term project , do one drug at a time , PAGE 46