How Do We Help Them - Deprescribing at EOLHow Do We Help Them - Deprescribing at EOL Ruth Medak, MD,...

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© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health. Oregon Hospice Association 2016 PPE “Creating a Cultural Mosaic” September 27, 2016 How Do We Help Them - Deprescribing at EOL Ruth Medak, MD, FACP Medical Director, Providence Hospice Gregory Dyke, RPh President Clinical Consulting, OnePoint Patient Care 1

Transcript of How Do We Help Them - Deprescribing at EOLHow Do We Help Them - Deprescribing at EOL Ruth Medak, MD,...

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Oregon Hospice Association 2016 PPE “Creating a Cultural Mosaic”

September 27, 2016

How Do We Help Them - Deprescribing at EOL

Ruth Medak, MD, FACP Medical Director, Providence Hospice

Gregory Dyke, RPh President Clinical Consulting, OnePoint Patient Care

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Bohemian Polypharmacy

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Bohemian Polypharmacy YouTube Video

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Objectives

• Define deprescribing and polypharmacy

• List at least 3 symptoms potentially aggravated at end of life (EOL) by frequently

prescribed medications

• List barriers to deprescribing medications

• Identify at least three classes of medications that are appropriate for

deprescribing

• Integrate strategies for discontinuing non-essential medications into the patient’s

plan of care

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“The task for the clinician is not to determine whether too many or

too few medications are being taken, but to determine if the patient is

taking the right medications”

Michael A. Steinman, MD

“Managing Medications in Clinically Complex Elders”

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Case Study

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Mary is a 78 year old female

− Conditions related to the terminal prognosis − Stage 4 NSCLC

− Comorbid conditions − DM Type 2, dementia (FAST 6d), hypertension, hypercholesterolemia, osteoporosis, anemia, insomnia

− Current history of symptoms− Cough, confusion, dyspnea, constipation, lightheadedness, incontinence, nausea

− Factors relevant to her current condition− Recent discharge from hospital secondary to a bout of pneumonia

− Recent problems swallowing, intermittent in nature

− Repeated falls in the past 3 months

− Vital Signs/Labs− BP 110/68 - FAST Level 6c

− Pulse 65/regular - Performance Status 40%

− Weight 110#

− HGB 10.8

− LDL-C 210

− BG 106

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Case Study – What would you do?

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MS ER 30mg q 12 hours

hydrocodone/APAP 5/325 q 4 hours prn

haloperidol 0.5mg q 4 hours prn

donepezil 10mg q HS

zolpidem 10mg q HS prn

ferrous sulfate 325mg TID

atorvastatin 40mg daily

MVI tablet daily

Glucovance 2.5/500 BID

lisinopril 10mg daily

omeprazole 20mg daily

Fosamax 70mg weekly

oxybutinin 5mg TID

Ca/Vitamin D daily

Preservision daily

Newly added at hospital discharge

Advair 250/50 BID

Spiriva Handihaler daily

levalbuterol inhaler q 4 hours prn

levofloxacin 750mg daily x 5 more days

promethazine/codeine 10ml q 4 hours prn

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Prescription drug use…prescribing inertia?(number of drugs taken concurrently: data 2007-2010)

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NOTE: Use is in the past 30 days. Except for age group estimates, percentages are age-adjusted.

SOURCE: CDC/NCHS, Health, United States, 2013, Figure 20. Data from the National Health and Nutrition Examination Survey.

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Over time, an aging population will drive drug use…

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US population > 65

years old

2013 - 44 million

2025 - 62 million

2035 - 77 million

2045 – 82 million

Baby Boomers

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Prescription drugs by therapeutic class(% of patients, by age group, taking at least one drug in the class - data 2007-2010)

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NOTE: Use is in the past 30 days. Cardiovascular agents include drug classes such as angiotensin-converting enzyme (ACE) inhibitors, beta blockers, calcium

channel blockers, and diuretics.

SOURCE: CDC/NCHS, Health, United States, 2013, Figure 21. Data from the National Health and Nutrition Examination Survey.

105 % increase

350 % increase

200 % increase

190 % increase

690 % increase

50% increase

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Models of healthcare delivery

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From Ray JPHAR:8341 Immunology, Rheumatology, Oncology & Transplant Therapeutics Source: Center to Advance Palliative Care

# of meds

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Why do we want to deprescribe?

Compelling Indications for Medication Discontinuation

• Changing goals of care

• Time to benefit

• Physiologic (organ system) changes

• Lack of efficacy

• Pill Burden

• Complexity of regimen

• Potential for a prescribing cascade

• Changed risk/benefit ratio

• Drug-drug interactions

• Drug-disease interactions

• Adverse effects

• Duplicate therapy

• Cost

• Regulations (CoP’s)

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Tools to assist deprescribing

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Prescribing Optimization

Method

Choosing Wisely Canada

Beers Criteria STOPP

START

ARMORGeriatric Palliative

Method

Anticholinergic Risk Scale

PLOS One Modified Delphi process for

Deprescribing

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Studies show…

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“The task for the clinician is not to

determine whether too many or too few

medications are being taken, but to

determine if the patient is

taking the right medications”

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Medication Appropriateness Index

Medication Appropriateness Index

1. Is there an indication for the drug?

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Example: PPI started in the hospital and

continued at discharge…forever

2. Will taking it increase comfort and quality of life for this person?

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The “low-hanging fruit”

• Medications that the patient…

– Does not want

– Cannot take

– Is not using

• Medications that cause unreasonable/

intolerable adverse effects

• Medications without clear benefit

– Drugs for primary or secondary prevention

– Some drugs for tertiary prevention

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What is the purpose of the medication?

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• No disease

• Avoids development of a disease

Primary Prevention

• Disease without symptoms

• Prevents progression of disease and emergence of symptoms

Secondary Prevention

• Disease with symptoms

• Reduces negative impact of already established disease

• Restores function, reduces disease-related complications

Tertiary Prevention

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Benefit of treatment

Is the patient truly more likely to be helped

or harmed by taking the drug?

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Harms

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Patients with prognosis of less than six months

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Virtually no benefit Benefit for selected patients

ALS and Huntington’s therapies in ES disease Allergy/cold medications

Androgens Anticoagulants

Appetite stimulants Antidepressants

Dementia drugs for ES disease Antiplatelet agents

Hormone replacement BPH medications

Hyperlipidemia medications Diabetes medications

Metered dose inhalers for ES COPD Gastric acid reducers

Multivitamins and supplements Gout medications

Osteoporosis drugs Homeopathic preparations

Incontinence medications

Thyroid hormone

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Medication Appropriateness Index

Medication Appropriateness Index

1. Is there an indication for the drug?

2. Will it increase comfort and quality of life for this patient?

3. What meaning does the drug have for the patient and family?

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Facts Feelings

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“My doctor told me I needed to take this

medicine for the rest of my life?”

“I don’t want my mother to die of a stroke”

“My medicines are working just fine”

“All I do is take pills”

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Barriers to discontinuing medications

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Barriers to Discontinuing Medications

at End-of-Life

Clinical Complexity

Rapidly progressing

disease trajectory

Ambiguous or changing goals

of care

Physiological or psychological attachment

Belief that medication

discontinuation = suboptimal

careFeelings of

abandonment or loss of hope

Lack of trust

Confrontation with mortality

Limited consultation time

Incomplete past medical history

Limited knowledge of harms

(continuing -discontinuing meds)

Multiple prescribers and fragmented care

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© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.

Medication Appropriateness Index

Medication Appropriateness Index

1. Is there an indication for the drug?

2. Will it increase comfort and quality of life for this patient?

3. What meaning does the drug have for the patient and family?

4. Is there duplication or a better choice?

5. Are there clinically significant drug-drug interactions?

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Medication Appropriateness Index

Medication Appropriateness Index

1. Is there an indication for the drug?

2. Will it increase comfort and quality of life for this patient?

3. What meaning does the drug have for the patient and family?

4. Is there duplication or a better choice?

5. Are there clinically significant drug-drug interactions?

6. Could the dose be reduced without harm? with benefit? In anticipation

of loss of swallow?

7. Are the directions practical?

8. Is this drug the least expensive appropriate alternative?

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Continue Treatment Stop Treatment

- Family resistant to discontinuation

- Patient has demonstrated beneficial effect

of drug on behavior

- No proven efficacy for FAST 7C or beyond

- No proven efficacy for treatment continued

beyond than 12 months

- Reduced pill burden

- Reduced cost of care ($200-250/month)

- Reduced potential for drug-drug

interactions and side effects

Dementia: To treat or not to treat

“It’s my view that [patients with dementia] should stay on [donepezil]

until they reach the stage of needing 24-hour assistance. At that point, I

would say that the drug has no value.”

David Knopman, MD, neurologist at the Mayo Clinic Alzheimer’s Disease Research Center

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Dementia treatment at EOL

• 2009 Survey of Hospice Medical Directors

– 75% reported that at least 20% of all patients were taking an AChE Inhibitor

– 33% reported that at least 20% of all patients were taking Namenda

– Majority said they did not believe either medication class was effective in persons

with end-stage dementia

• 80% recommended discontinuing these therapies

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Pulmonary medications – 3 “rights”

• Right drugs

• Right doses

• Right delivery method

For people with ES COPD consider routinely

switching to nebulized medications

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Dyspnea Cycle

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Diabetes treatment goals

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Life expectancy

Patient and family

concerns/beliefs

Risk and impact of hyper and

hypoglycemiaOral Intake

Medication and management

burden

Sweet

Spot

Find the Sweet Spot

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Diabetes treatment goals

Conventional

Early treatment goal

End-of-life

Hospice / palliative care goal

• Optimize length of healthy life

• Tight control of glucose, lipids, and

BP to reduce complications from

micro- and macrovascular disease

• Optimize quality of life

• Looser glucose control to minimize

symptoms of hypoglycemia as well

as hyperglycemia

• Reduce medications to minimize

pill burden, adverse effects and

burden of monitoring

• Allow patients to eat what they like

and want

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Deprescribing diabetes medications

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Patient

Categories

Enteral

Intake

Treatment Approach

Active Disease

but Relatively

Stable

Fair with

sporadic

improvements

or worsening

Prevent hypoglycemia

• Begin dialog about redefining control to prevent symptoms (140-

250 or even 350) and adjust medications accordingly

DM1: Continue insulin to prevent diabetic ketoacidosis (DKA)

DM2: Continue insulin if prone to symptomatic hyperglycemia

Impending

Death or Organ

or System

Failure

Declining

calorie intake

with anorexia

Prevent hypoglycemia

• Reduce or discontinue insulin and medication

Actively Dying None Patient comfort

• Reduce or discontinue insulin and medication

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Yvonne Morrissey, Michael Bedford, Jean Irving, Chris K. T. Farmer. Older people remain on blood pressure agents despite being hypotensive

resulting in increased mortality and hospital admission. Age and Ageing, 2016; DOI: 10.1093/ageing/afw120

What blood pressure target is right when prognosis is short?

• Medication side effects may decrease quality of life

• Both high and low blood pressure correlate with increased mortality in end stage

– heart failure

– liver disease

– CAD

– Chronic kidney disease

– Cerebrovascular disease

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Evidence of even

this value is poor.

Consider treating

at SBP> 160 or

emergence of

symptoms

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Adverse effects of anti-hypertensives

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Class Adverse Effects

ACE Inhibitors Hyperkalemia, dry cough

Angiotensin Receptor Blockers Dry cough, chest pain, diarrhea

Alpha1-Blockers Edema

Alpha2-Agonists Xerostomia, edema

Beta-Blockers Bradycardia, bronchospasm (non-selective agents)

DHP Calcium Channel Blockers Edema, nausea, flushing

Non-DHP Calcium Channel

Blockers

Edema, pain, bradycardia, constipation

Diuretics Electrolyte imbalance, dehydration

All antihypertensives have the potential to cause

hypotension, dizziness, weakness, and fatigue

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Anti-platelet agents – risk vs. benefit

• Is anti-platelet therapy a palliative intervention?

– 25% relative risk reduction

– Benefits survival over long-term

• 36 events prevented per 1,000 patients treated for 29 months (870 days)

– No evidence of decreased symptom burden

• Options: aspirin, Plavix (clopidogrel), Aggrenox (E.R. aspirin/dipyridamole)

• All approximately equally effective as monotherapy in most circumstances

• Combination aspirin + Plavix = increased bleeding risk

– Aggrenox – 40% get headaches after 1st dose

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Anti-platelet therapy is not typically a palliative intervention

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Plan ahead for loss of swallow

Drugs that should not be abruptly discontinued

• Gabapentin – 25% reduction per week

• Antidepressants – over 4 weeks, however tapering not necessary if life

expectancy is 1 week or less (symptoms begin to peak at 1 week (particularly

Paxil)

• Clonidine – over 2-4 days

• Antipsychotics – over 1-2 weeks

Alternative medications (to use)

• Methadone for neuropathic pain

• Fluoxetine for depression (long t1/2)

• Valproic acid, diazepam tablets, or phenobarbital for seizure prophylaxis

• Nitroglycerin paste for angina prophylaxis

• Haloperidol or valproic acid for behavioral disorders in dementia

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Deprescribing medications: a four step approach

1. Understand the reasons for discontinuing medications

– Diminished benefit

– Increased risk for adverse events

– Risk outweighs benefit

2. Identify/prioritize medications targeted for discontinuation

– Review of medical history, vital signs, clinical status/prognosis

– Communicate rationale with patient/family

3. Discontinue medication

– If time allows, taper medications with potential for withdrawal

4. Monitor patient for harmful or beneficial effects

– Physiological withdrawal

– Exacerbation of condition

– Onset of new symptoms

– Improvement of symptoms

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A prescribing model for end-of-life care

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Holmes, HM et al. Rational prescribing for patients with a reduced life

expectancy. Archives of Internal Medicine. 2006;166;605-9.

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Conclusions

• Recognize that reduced remaining life expectancy presents an opportunity to re-

examine once appropriate therapies

• Many patients are willing to consider deprescribing if their physician thought it

appropriate

• Deprescribing is a patient-specific exercise

• Weigh risks vs. benefits of continued use of all medications at EOL in a manner

consistent with the patients goals of care

• Discontinue medications to:

– Improve quality of life

– Reduce adverse effects

– Resolve duplicate therapy

– Control costs

• Change the prescribing paradigm

From: Start low, go slow

To: Stop most, reduce dose

40

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Bohemian Polypharmacy

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Bohemian Polypharmacy YouTube Video

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Appendix

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Rationale to support deprescribing

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Drug Class Indications to Discontinue

AChE Inhibitors• FAST 7C or beyond; no proven efficacy for end-stage disease

• Cost of medication, adverse effects outweigh benefit

ALS Agents• Cost of medication/adverse effects such as nausea, vomiting, and fatigue outweigh

benefit

• Non-palliative medication

Antibiotics• Treatment with antibiotics is not to relieve symptoms of the infection

Anticoagulants• Injections, required monitoring are too much of a burden for the patient

• Risk of falls and/or bleeding outweigh the benefit of prophylaxis

Antihypertensives• Weight loss; hypotension

• Aggressive treatment of hypertension may not benefit patients >75 years old

Antiparkinsons Agents • Adverse effects outweigh benefit of continued use

Antiplatelets• The risk of bleeding outweighs the potential benefit

• Non-palliative medication

Asthma/COPD inhalers• Failure to meet minimum inspiratory flow requirements; patient lacks

coordination/cognitive ability to use properly

• No relief of symptoms despite use

Bisphosphonates

• Dysphagia; delayed esophageal emptying; patient cannot sit upright for 30 minutes after

dose; CrCl <35 ml/min

• Consider prognosis: stopping the drug not associated with increased risk of vertebral/hip

fracture

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Rationale to support deprescribing (cont.)

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Drug Class Indications to Discontinue

Chemotherapy• The medication has been given an adequate trial and found to be ineffective, non-

palliative

• Cost of medication, adverse effects outweigh potential benefits

Hematopoietic Agents• Epoetin/darbepoetin: inadequate iron stores; Hgb >10 g/dL; uncontrolled hypertension

• Cost of medication, adverse effects outweigh potential benefits

HMG CoA Reductase

Inhibitors

• Inconsistent evidence for effect of overall and cardiovascular mortality in patients 70-82

years old

• Non-palliative medication; cost of medication, adverse effects outweigh potential benefit

IV Fluids

• Patient experiencing peripheral edema, difficulty breathing, increased blood pressure

• Terminally dehydrated patients may be less aware of pain than medically hydrated

patients

NMDA Receptor

Antagonist

• FAST 7C or beyond; no proven efficacy for end-stage disease

• No significant benefits in mod-severe Alzheimer’s Disease when in combo with donepezil

Opioids• Fentanyl: Limited prognosis; fluctuating pain level; unpredictable absorption in patients

who are cachectic, morbidly obese, edematous, febrile.

Proton Pump Inhibitors• No clear indication for therapy (GERD, active ulcer, concomitant NSAID/steroid, etc.)

• Risk of adverse effects with continued use (drug-drug interactions, fracture, c. diff, etc.)

Vitamins• Not offering any improvement In quality of life

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References

1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.

Journal of the American Geriatrics Society. 2012;60(4):616-631.

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