Deprescribing, Medication Therapy Management Go Hand in Hand

Evidence suggests that the risk of experiencing an adverse drug event (ADE) is 88% higher in patients taking 5 or more medications, which is also known as polypharmacy.¹

Advanced patient age, cognitive impairment, and mental health conditions are a few examples of risk factors for polypharmacy.² Deprescribing is a process that may improve medication safety and reduce ADEs. It involves supervised medication discontinuation or dose reduction to reduce the use of potentially inappropriate medications (PIMs).² Pharmacists can play a key role in deprescribing as part of a multidisciplinary health care team through medication therapy management (MTM) consultations (Figure^1-5).

The American Society of Health-System Pharmacists recommends performing MTM consults that include comprehensive medication reviews (CMRs) before additional medications are prescribed for patients already taking 5 or more medications.³ Pharmacists should review all OTC and prescription medications, assess for drug interactions, and evaluate for appropriate dosing.³ The MTM consult can reveal whether certain medications should be discontinued based on patients’ medical conditions, which sets the stage for depre-scribing. Medications that are typically eligible for deprescribing have the following characteristics: drug-drug, drug-disease, or drug-food interactions; duplication of therapy; inappropriate dosing (hepatic or renal impairment); and no valid indication based on the patient’s medical history.²

There are a variety of tools pharmacists can use to assess polypharmacy. The Beers Criteria, the Medication Appropriateness Index (MAI), and the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria are a few examples.¹ The Beers Criteria includes a list of PIMs that older adults should avoid in most cases or in specific instances.¹ The MAI includes 10 questions with ratings, and the STOPP criteria contain a list of PIMs for older adults.¹

Polypharmacy can cause a variety of negative outcomes, such as decreased quality of life, falls, hospitalization, and mortality.² Ensuring patients have an up-to-date medication list is critical when it comes to deprescribing.³ Additionally, it should include all OTC and prescription medications. Pharmacists should frequently follow up with patients after discontinuing or lowering the medication dose and communicate updates with the other members of the health care team.

Evidence shows that pharmacists play a critical role in leading deprescribing. An observational study examined the effectiveness of pharmacist interventions to detect PIMs and reduce the number of medications in patients’ drug regimens.⁴ The study results showed that the proportion of patients whose medication regimens were reduced was higher in the pharmacist intervention group (P < .001).⁴

The results of one recent study published in JAMA Internal Medicine showed that deprescribing interventions led by nurse practitioners and pharmacists was effective at reducing the medication burden.5 The Shed-MEDS randomized trial (NCT02979353) evaluated comprehensive deprescribing in the hospital among older adults receiving ongoing care in a post–acute care (PAC) facility.⁵ The intervention group consisted of the Shed-MEDS inter-vention involving a nurse practitioner– or pharmacist-led CMR and deprescribing that continued throughout the PAC facility stay.⁵ Study participants in the control group received the standard of care at the hospital and PAC facility.⁵

There were 372 participants randomly assigned to the intervention or control groups, and 284 were included in the intention-to-treat analysis. The randomly assigned patients included in the statistical analysis.5 The average age of study participants was 76 years.⁵ Participants in the intervention group were taking an average of 14% fewer medications at PAC facility discharge (P < .001) than participants in the control group.⁵ Additionally, patients in the intervention group were taking on average 15% fewer medications at the 90-day follow-up (P < .001) than patients in the control group.⁵

References

1. Takhar S, Nelson N. Deprescribing as a patient safety strategy. Agency for Healthcare Research and Quality. October 27, 2021. Accessed April 13, 2023. https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy

2. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. Am Fam Physician. 2019;100(1):32-38.

3. Five things physicians and patients should question. American Society of Health-System Pharmacists. Updated June 20, 2019July 14, 2022. Accessed April 14, 2023. https://www.choosingwisely.org/societies/american-society-of-health-system-pharmacists

4. Kimura T, Fujita M, Shimizu M, et al. Effectiveness of pharmacist intervention for deprescribing potentially inappropriate medications: a prospective observational study. J Pharm Health Care Sci. 2022;8(1):12. doi:10.1186/s40780-022-00243-0

5. Vasilevskis EE, Shah AS, Hollingsworth EK, et al. Deprescribing medications among older adults from end of hospitalization through postacute care: a Shed-MEDS randomized clinical trial. JAMA Intern Med. 2023;183(3):223-231. doi:10.1001/jamainternmed.2022.6545

About the Author

Jennifer Gershman, PharmD, CPh, PACS, is a drug information pharmacist and Pharmacy Times contributor who lives in South Florida.