Australian Doctor 4th August 2023 AD 4th Aug Issue | Página 48

decisions apply in RACFs as they do

in the community ; consciously resist the institutional model of care , paternalism , ageism and patient disempowerment . Ask the service for families , where wanted by the patient or where required for consent , to be involved in discussion at the time of consultation

dakaufman123 / bit . ly / 3DQHd36

pain ?” with a “ No ”, or “ I don ’ t know ”, then deprescribe this medication . If the pain does not clearly recur or worsen on deprescribing , this is further evidence the medication was not helpful . Pain that improves while a person is on medication is not evidence that the medication has caused

either on the phone or in person , as you

the improvement . This false assump-

would in your office .

tion may lead to patient reluctance to

MINDFUL REPRESCRIBING – A PRACTICAL APPROACH

IF all prescribed medications were

intended to continue indefinitely there

deprescribe and can often be resolved with discussion . Many chronic or acute pain issues self-resolve , are self-limiting or episodic . 22

Is it causing harm ?

Responsible prescribing outlines pos-

would be little need for repeat pre-

sible side effects , interactions , phys-

scriptions from a doctor . The purpose

iological and functional impacts .

of represcribing is to check that the

Enquiring about their presence will

medication is still indicated , is still the

prompt discussion about the risk –

best option for the condition and the

benefit balance in individual patients

patient , to check that it is having the

and may guide deprescribing . Always

desired effect , to assess for side effects

consider whether a new symptom

or interactions , to confirm the dose is

or problem is medication related .

still appropriate and , importantly , to

Treatment then may be deprescrib-

check it is still wanted by the patient .

ing rather than adding a new product ,

These checks ( see box 4 ) will

thus avoiding a prescribing cascade .

become quick and automatic once

Single medications can have trou-

incorporated into the represcribing

blesome side effects in some patients ;

thought process ; apply each time a

this is compounded and far more

prescription is rewritten or a medica-

common in polypharmacy , multiple

tion chart is rolled over . Failing to con-

morbidities and the frail elderly .

sider these issues amounts to mindless

The potentiation of pharmaco-

rollover and makes it very difficult

logical effects and compounding of

to routinely consider deprescribing .

side effects can be hard to recognise ,

These factors , when presented to the

especially in those who are unable to

patient , also form the fundamental

communicate easily or who have cog-

components of informed consent .

Indication

Understanding the indication may

nitive impairment . This is the group most vulnerable to insufficient attention to medication-related harm , and who may benefit greatly from

expose unsatisfactory reasons for con-

thoughtful deprescribing .

tinuation of a medication . Depend-

There are tools available , such

ence and fear of withdrawal are very

as the drug burden index , to look at

real issues in patients taking drugs of

anticholinergic burden . 24

addiction ; this may need long engage-

Anticholinergic side effects include

ment or expert assistance and advice and significant support . If it is clear

Figure 6 . Medication list for a bed-bound nursing home patient .

constipation , confusion and hallucination , memory disturbance , dry

the indication for a drug of addiction is one that is family driven rather than patient driven , then this needs caution and definite addressing . For example , a family member insists that a patient needs ongoing opiates , including patches , or benzodiazepines in the absence of any symptoms that would warrant their use , and there are grounds to suspect this medication is being abused by others or diverted onto the black market .

Present the absence of an indication as a positive outcome for patients ; they have recovered or no longer need that medication . If patients are resistant to deprescribing , point out that the medication is not providing a benefit , may

Box 4 . Mindful represcribing

• Is the indication still clear and applicable ?

• Is this medication the best option ? — Consider non-pharmacological alternatives , newer medications , more targeted or specific , easier schedules or regimes .

• Is it actually working ?

• Is it causing harm ? — Check interactions , blood tests and side-effect symptoms and signs .

• Is the dose / regimen appropriate or can it be reduced ( either the dose or frequency )? — Same effect at a lower dose , trial of deprescribing .

• Does the patient still want it ? — Are they consenting , considering all the factors in the decision , or merely agreeing ? — Are they trying to please you ? — Have their goals changed ?

Is it working ?

When a medication is initiated for a

particular indication , it is fundamental to expect a benefit from that medication . If that expected benefit does not occur , it is important that this is recognised early , and the medication stopped . If medication is still thought to be indicated , then try an alternative . If a medication is not working , it is easy to add another drug ; however , it is usually better to substitute another drug for it . This is deprescribing one medication to prescribe another . It allows the second drug the opportunity to be evaluated alone and prevents the risk of compounding any adverse effects .

mouth and eyes , falls , urinary retention and drowsiness / sedation . These may all be incorrectly attributed to ‘ old age ’. Impacts of sedation in the elderly include reduced oral intake with malnutrition and dehydration , falls , physical deconditioning with loss of independent function , pressure injury , reduced ability to interact meaningfully with loved ones or carers and reduced ability to participate in pleasurable activity ( see figure 7 ). 25 The sensitivity of the frail and cognitively impaired elderly patient makes these impacts particularly marked . The reduction of quality of life can be profound , and deprescribing can make a real and satisfying improvement .

be causing harm and should not be

A drug that is not working is generally

Many individual agents are costly ,

used . Sometimes the practitioner may

not required and should not be used .

and polypharmacy can be expensive .

need to explain they can no longer ethically prescribe a medication that cannot be justified , has no rationale and no

chronic pain , anxiety , depression , insomnia and constipation . 16 This is an opportunity to review treatable causes

Other drugs occasionally encountered are barbiturates for epilepsy or older beta blockers such as propran-

If a drug is used to treat a condition that can be monitored , for example blood pressure or blood markers ,

The financial burden is rarely considered and may be a significant additional incentive to deprescribing .

potential for benefit . Patients cannot compel a doctor to prescribe .

Medications intended to be tempo-

of the condition and assess whether the current approach is still the best option . Routine represcribing can lead

olol for hypertension or cardiac rate control , which can be updated to a more cardio-specific medication such

these may be used as an indication that the medication is of benefit . If a drug is being used only for symptom

Dose / regimen

Reducing the dose or frequency of

rary that may be continued indefinitely

to prolonged use of drugs that are no

as metoprolol , with a better side-effect

management and the patient does not

a drug is a form of deprescribing . In

include anticoagulation after DVT , cor-

longer the best option for the condi-

profile . Older antipsychotics such as

think it has helped , there is no bene-

general , prescribe the lowest effective

ticosteroids for acute pulmonary and

tion , if indeed the condition still exists .

chlorpromazine have modern alterna-

fit to be gained and the drug should be

dose ; if this dose is effective , reduc-

dermatological conditions , sedatives

For example , a patient with chronic

tives with much fewer adverse effects .

stopped .

ing the risk of side effects is achieved .

( for example , antipsychotics or benzo-

dizziness who has been treated for a

Prednisone has a significant

Non-opiate medication , such as

Changes in body weight or change in

diazepines ) to manage transient behav-

long time with prochlorperazine is still

adverse effect profile , particularly

gabapentinoids ( pregabalin and gab-

the patient condition / s and the pres-

iour concerns or acute postoperative or

unsteady and falling . This suggests the

with prolonged use . It is impor-

apentin ) or anticonvulsants ( val-

ence of possible side effects should

ICU care and analgesics for acute pain .

medication is not working . A review

tant to understand the condition

proate ) are commonly used to treat

trigger a review of the dose .

Best option

Once the indication for use of a medication

has been clearly established , consider if medication is the best way

of the dizziness indicates there may be a component of vertigo present and a specialist referral is made . Testing confirms benign paroxysmal positional vertigo and an Epley manoeuvre

that is being treated and consider newer disease-modifying agents , for example in rheumatoid arthritis , or whether the agent was intended for short-term use , such as post-exacer-

pain . There is , however , very limited evidence for efficacy in chronic pain , even when there is associated neuropathy . 22 There is increasing recognition of the impact of adverse effects

Patients usually welcome a simplified medication regimen . Remembering to take medication can be problematic and burdensome . It is easier to take all medications at

to manage this condition . Many people are open to suggestions of non-phar-

is successfully performed . The patient has stopped falling and no longer

bation COPD , or whether review and tapering was intended , as in polymy-

of these medications 23 If a patient responds to the ques-

one time of day rather than several times a day , and when a carer

macological alternatives to manage

requests medication .

algia rheumatica .

tion : “ Has the pregabalin helped your

administers medication .