Polypharmacy and hyperpolypharmacy deprescribing Creating appropriate interventions to assess, educate, inform, and strategize meaningful next steps sensitive to patient desires, needs, and medication-related beliefs, polypharmacy and hyperpolypharmacy can also include deprescribing medications. Deprescribing medications can be done according to best practices by understanding the health needs of each patient relative to medication-induced effects, prior to reconciliation. Categorizing health-related groups based on respective condition and health risk will provide some insight into the possibility of medication impact. For example, categorizing each patient by various risks can help identify trends, new symptoms, side effects, or other concerns, physician can correlate integration of new medication and potential impact (Rana et al., 2022): ● Frailty ● Fall risk ● Dementia ● Cardiovascular comorbidities ● Diabetes Once the respective conditions and comorbidities for the respective patients have been identified, verification of all medications should be the next step. Verifying medication should include (Rana et al., 2022): ● Medication name ● Dosage ● Frequency ● Formulation ● Time For older adults living in a skilled nursing facility or nursing home, medication reconciliation should be done upon admission, whenever there is a transfer or transition, and upon discharge from a hospital or other setting. For patients in the community, medication reconciliation should be done as often as possible, especially at every office visit. Patients with polypharmacy and hyperpolypharmacy should have their medications reviewed by a clinical pharmacist whenever there is a medication change. If there are no changes, medication should be reviewed each time a patient sees their provider. If a patient sees a specialist at other times, it is imperative that any changes in medication ● Route of administration ● Indication of medication
are reviewed by their primary care provider as well as the pharmacist. Of note is the importance of patient self- reporting over-the-counter medications and supplements they are also taking. Responsible adherence to medications, in any environment, will help capture and measure the following (Rana et al., 2022): ● Changes in complexity of medication regimen ● Compliance with clinical practice guidelines ● Adverse effects ● Alternative options ● Clinical response ● Clinically significant drug-drug interaction ● Other potential interventions According to Rana et al. (2022), engaging pharmacists in the deprescribing process can potentially lead to greater outcomes with a recent systematic review showing a 35% of risk reduction in pharmacist-led interventions, in particular with potentially inappropriate medication (PIM) occurrences. Specially, pharmacists in these studies used evidence-based tools, including the Beers Criteria and the Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tools to Alert Doctors to the Right Treatment (START) (Verghese et al., 2023). Drug reconciliation also has clinical and economic impact for both patient and healthcare system: ● Can prevent polypharmacy and potential drug interactions ● Limits adverse events ● Can reduce polypharmacy related hospitalizations, fall risks, and prescription cascade, as well as other complications ● Ensures that patients have accurate medication lists, reduces duplication opportunity, and provides consistency for patient-centered and continuum of care ● An expected cost savings that can be an outcome of drug reconciliation prior to each change in health status and transition for polypharmacy and hyperpolypharmacy patients To ensure proper patient care and mitigation of withdrawal side effects, the steps in Table 14 are recommended for deprescribing pharmaceuticals.
Table 14: General Steps to Deprescribing Step
Additional Insight
Review all current medication
Create a consolidated list of all medications, over-the-counter drugs, and supplements Identify purpose and intent of each item
Identify potentially inappropriate medication (PIM) Assess patient’s health status
Gain insight into the intent behind these items
Consider patient’s overall health, comorbidities, and social determinants of health
Prioritize medication
Focus on medications with limited benefits and safety issues
Involve the patient in shared decision-making Start the process, but slowly Monitor for withdrawal symptoms Reference deprescribing guidelines
Discuss rationale, intent, and purpose behind each medication
Gradually reduce dosage or frequency, monitoring patient’s progress
While monitoring, pay close attention to negative effects or changes
Follow guidelines and track accordingly
Document the deprescribing plan Tailor guidelines to patient’s needs and response
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Book Code: MTX1326
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