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Deprescribing at the End-of-Life: Less is More James B. Ray, PharmD, CPE The James A. Otterbeck Professor of Hospice & Palliative Care University of Iowa College of Pharmacy [email protected] 11/18/2015 Brief background - definitions and statistics • Deprescribing – systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits in the context of an individual patients’ care CASES – • Packet of patient cases • Task – Identify which medications you would deprescribe – Share rationale – Prioritize….which would you DC first? Treatment Target Goals of Care Time Until Benefit Remaining Life Expectancy Goals of Care • Clinical judgement and patient guided decision making – Ongoing discussion • Standards of care and practice guidelines can be momentarily forgotten Statins • Hyperlipidemia increases with age • However, very old, severely ill patients, and actively dying patients may having declining LDL and TC levels • Too low of TC may be a marker of poor outcomes • Time-to-benefit for statins – 2-6 years • Burdens of statins: – – – – – Myopathy and myalgias Fatigue Pill burden Lab testing Cost http://www.cliparthut.com/sleeping-with-woman-at-desk-clipart.html Bisphosphonates • • • Proven benefit for fracture prevention in osteoporosis and for women on anti-estrogen therapies Correct duration of therapy is unknown Risks of bisphosphonates include: • Short term » Headache, dyspepsia, abdominal pain, gastrointestinal ulcers, muscle cramps • Long term » Bone fractures, chronic bone/joint/muscle pain, osteonecrosis of the jaw, severe hypocalcemia • Issues at the end-of-life – – – – – Administration Cost Adverse effects Quality of life Extended efficacy? http://www.myfamilymeddocs.com/service/osteoporosis/ Anti-hypertensives • Primary prevention of cardiovascular disease and kidney disease • BP is used as a surrogate marker for control • Guideline driven care with specific BP targets – often >1 drug • Issues at the end-of-life • • • • • Fatigue Hypotension Orthostasis Falls Cognitive impairment The how? Evidence-based recommendations: How do I stop it? Benzodiazepines • If used daily for more than 3-4 weeks then: • Reduce dose by 25% every week (i.e. week 1-75%, week 2-50%, week 3-25%) • If intolerable withdrawal symptoms occur (usually 1-3 days after a dose change), go back to the previously tolerated dose until symptoms resolve and plan for a more gradual taper with the patient • Dose reduction may need to slow down as one gets to smaller doses (i.e. 25% of the original dose) • The rate of discontinuation needs to be controlled by the person taking the medication. Benzodiazepines • Symptoms to monitor for: – Rebound insomnia – Tremor – Anxiety – Hallucinations – Seizures – Delirium Opioids • If used daily for more than 3-4 weeks then: • Reduce the dose by 25% every 3 to 4 days • Once at 25% of the original dose and no withdrawal symptoms have been seen, stop the drug • If any withdrawal symptoms occur, go back to approximately 75% of the previously tolerated dose. Opioids • Symptoms to monitor for: – Restlessness – Runny nose – Goose flesh – Sweating – Muscle cramps – Insomnia – Pain – Secretion of tears – Dilation of the pupils – Breathlessness – Decrease or impairment in daily function Beta Blockers • If used daily for more than 3weeks: – Reduce dose by 50% every 1 to 2 weeks (7-10 days) – May stop once at 25% if not symptomatic – Metoprolol and atenolol • Symptoms to monitor for: – Chest pain – Pounding heart – Blood pressure – does it need to be re-measured? – Anxiety – Tremor http://thinkprogress.org/health/2013/01/31/1517821/fetal-heartbeat-bills-to-watch/ Clonidine • If used for >1 week: – Reduce dose by 50% every week – May taper over 2-4 days – Oral versus patch? • Symptoms to monitor for: – Rebound hypertension – Headache – Insomnia – Tachycardia – Hiccups – Salivation http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=20848 Anti-depressants • Depends on the agent! – Paroxetine and venlafaxine – Fluoxetine • Taper over several months – reduce the dose by 25% every 4 to 6 weeks • Symptoms to monitor for: – Insomnia – Flu-like symptoms – Imbalance – Sensory experiences (electric shock-like feelings) – Hyperarousal – N/V/D – Agitation Baclofen • Taper over 2-4 weeks • Decrease dose by 25% every week • Symptoms to monitor for: – High fever – Altered mental status – Muscle rigidity – Muscle cramps and pain • Re-initiate therapy if symptoms are intolerable at 75% of the original dose Others • • • • • • • Tizanidine Corticosteroids Anti-psychotics Gabapentin Anti-epileptics Carisoprodol Nitrates Be an advocate for your patients • Help patients understand WHY a medication may not be appropriate any longer • Discuss how they may feel after stopping the medication • Tell them HOW you are going to stop the medication • WHAT are you going to do if symptoms come back? • Use conversation to help understand your patient’s treatment target, goals of care, and overall wishes about medications