Feasibility and effectiveness of deprescribing benzodiazepines and Z-drugs: systematic review and meta-analysis

The Impact of Deprescribing Interventions on the Drug Burden Index and Other Outcomes: A Systematic Review

OBJECTIVES

The Drug Burden Index (DBI) calculates a person's exposure to anticholinergic and sedative medications. We aimed to review randomized controlled trials (RCTs) of deprescribing interventions that reported the DBI as an outcome, their characteristics, effectiveness in reducing the DBI, and impact on other outcomes.

DESIGN

Systematic review with meta-analysis.

SETTING AND PARTICIPANTS

RCTs of deprescribing interventions where the DBI was measured as a primary or secondary outcome in humans within any setting were included.

METHODS

Electronic databases, citation indexes, and gray literature were searched from April 1, 2007, to September 1, 2023. Quality was assessed using the Cochrane risk-of-bias tool.

RESULTS

Of 1721 records identified, 9 met the inclusion criteria. Six interventions were delivered by pharmacists and 3 were delivered by pharmacists/nurses or pharmacists/geriatricians. All interventions required at least intermediate-level skills and involved multiple components and target groups. Studies were conducted in the community (n = 5), nursing homes (n = 2), and hospitals (n = 2). The mean or median age was ≥75 years and most participants were women in all studies. Most (n = 6) studies were underpowered. The follow-up period ranged from 3 to 12 months. Three studies reported a lower DBI in the intervention group compared with control: 1 pharmacist independent prescriber-delivered in nursing homes (adjusted rate ratio, 0.83; 95% CI, 0.74 to 0.92), 1 pharmacist/nurse practitioner-delivered in hospital (adjusted mean difference (MD), -0.28; 95% CI, -0.51 to -0.04), and 1 geriatrician/pharmacist-delivered in hospital (MD, -0.28; 95% CI, -0.52 to -0.04). Meta-analysis showed no difference in the change in DBI between control and intervention groups in the community including nursing homes (MD, -0.03; 95% CI, -0.08 to 0.01) or hospital setting (MD, -0.19; 95% CI, -0.45 to 0.06). Interventions had inconsistent effects on cognition and no effect on other reported outcomes.

CONCLUSIONS AND IMPLICATIONS

RCTs of deprescribing interventions had no significant impact on reducing DBI or improving outcomes. Further suitably powered studies are required.

Evaluation of a benzodiazepine deprescribing quality improvement initiative for older adults in primary care

BACKGROUND

Older adults are commonly prescribed long-term benzodiazepines for anxiety and insomnia despite evidence of risks and limited evidence of long-term benefits. Recent quality measures and guidelines have recommended benzodiazepine deprescribing, yet there is little real-world data on clinic-based deprescribing programs.

METHODS

We developed a benzodiazepine deprescribing quality improvement program for older adults at a large US academic medical center. The program targeted adults aged 65 years and older who were prescribed chronic benzodiazepines by their primary care physician (PCP). PCPs were contacted to opt-out patients not suitable for deprescribing; then eligible patients were mailed a letter discussing patient-specific risks and advising them to discuss deprescribing with their PCP or a pharmacist who was available to support tapering. The primary outcomes were the number of patients who discussed deprescribing and who initiated a taper within 90 days of outreach.

RESULTS

Of 504 older adults prescribed benzodiazepines, 133 (26%) were opted out by their PCPs leaving a cohort of 371 (median age 71 years [IQR 68-75], 58% female, 82% White). The median daily diazepam milligram equivalent was 5 mg (IQR 3-6 mg) and 30% were prescribed long-acting benzodiazepines. Three months following patient outreach, 97 patients (26%) had a documented discussion of benzodiazepines with their PCP or clinic pharmacist. Of these patients, 35 (36%) had documentation of a deprescribing discussion and 25 (26%) initiated a taper. At 12 months, 16 patients (64%) were tapered successfully, with nine (36%) patients taking a lower benzodiazepine dose and seven (28%) discontinuing benzodiazepines completely.

CONCLUSIONS

A low-intensity benzodiazepine deprescribing outreach program led to deprescribing conversations for a minority of patients, but one-quarter of older adults who engaged in a conversation chose to taper and nearly two-thirds sustained reduced use. Incorporating benzodiazepine deprescribing into routine care may require more intensive population-health efforts to engage patients and clinicians.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

The PROMISING Project: A Pilot Study to Improve Geriatric Care Through a Pharmacist-Led Psychotropic Stewardship Program

BACKGROUND AND OBJECTIVE

Psychotropic medications are frequently prescribed during acute care, even in older patients. They represent a risk for inappropriate long-term use and increase the overall risk of morbidity and mortality in this population. Our project aimed to evaluate the feasibility of a psychotropic medication stewardship program led by pharmacists.

METHODS

We conducted a prospective, observational pilot study in patients aged 75 years and older, admitted to a surgical unit with at least one active prescription of a psychotropic medication (antipsychotic, benzodiazepine or non-benzodiazepine receptor agonist). Each psychotropic medication was assessed for potential deprescription, and if eligible, a recommendation from the stewardship pharmacist was made to the medical team.

RESULTS

Among 183 patients, 93.4% were eligible for a potential deprescription. A total of 298 prescriptions were evaluated by the stewardship pharmacists, of which 57.7% were antipsychotics, 22.8% were benzodiazepines and 19.5% were non-benzodiazepine receptor agonists. Most of the assessed prescriptions were started during current hospitalization (62.7%). The median time required for the intervention per patient was 17 min 30 s. The stewardship pharmacists made 192 suggestions for 258 eligible prescriptions, with 69.8% being deprescription recommendations. Of all the deprescription suggestions, 75.4% were accepted by the medical team and 84.8% of those accepted persisted at discharge.

CONCLUSION

The implementation of a pharmacist-led psychotropic medication stewardship program on surgical units in our hospital is feasible and is a promising approach to improve geriatric care.

Long-term use of benzodiazepines in chronic insomnia: a European perspective

Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.

Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review

BACKGROUND

Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations.

METHODS

We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations.

RESULTS

Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes.

CONCLUSIONS

This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.

The impact of a pharmacist intervention on post-discharge hypnotic drug discontinuation in geriatric inpatients: a before-after study

BACKGROUND

Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients.

METHODS

A before-after study was performed on the acute geriatric wards of a teaching hospital. The before group (= control group) received usual care, while intervention patients (= intervention group) were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, patient education and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge. Secondary outcomes among others were sleep quality and hypnotic use at one and two weeks after enrolment and at discharge. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) upon inclusion, two weeks after enrolment and one month after discharge. Determinants for the primary outcome were identified using regression analysis.

RESULTS

A total of 173 patients were enrolled, with 70.5% of patients taking benzodiazepines. Average age was 85 years (interquartile range 81-88.5) and 28.3% were male. A higher discontinuation rate at one month after discharge was observed in favour of the intervention (37.7% vs. 21.9%, p = 0.02281). No difference in sleep quality was found between both groups (p = 0.719). The average sleep quality was 8.74 (95% confidence interval (CI): 7.98-9.49) and 8.57 (95% CI: 7.75-9.39) in the control and intervention groups respectively. Determinants for discontinuation at one month were: the intervention (odds ratio (OR) 2.36, 95% CI: 1.14-4.99), fall on admission (OR 2.05; 95% CI: 0.95-4.43), use of a z-drug (OR 0.54, 95% CI: 0.23-1.22), PSQI score on admission (OR 1.08, 95% CI: 0.97-1.19) and discontinuation prior to discharge (OR 4.71, 95% CI: 2.26-10.17).

CONCLUSIONS

A pharmacist-led intervention in geriatric inpatients was associated with a reduction of hypnotic drug use one month after discharge, without any loss in sleep quality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05521971 (retrospectively registered on 29^th of August 2022).

Nitrazepam and 7-aminonitrazepam studied at the macroscopic and microscopic electrified liquid-liquid interface

Two benzodiazepine type drugs, that is, nitrazepam and 7-aminonitrazepam, were studied at the electrified liquid-liquid interface (eLLI). Both drugs are illicit and act sedative in the human body and moreover are used as date rape drugs. Existence of the diazepine ring in the concerned chemicals structure and one additional amine group (for 7-aminonitrazepam) allows for the molecular charging below their pKa values, and hence, both drugs can cross the eLLI interface upon application of the appropriate value of the Galvani potential difference. Chosen molecules were studied at the macroscopic eLLI formed in the four electrode cell and microscopic eLLI formed within a microtip defined as the single pore having 25 μm in diameter. Microscopic eLLI was formed using only a few μL of the organic and the aqueous phase with the help of a 3D printed cell. Parameters such as limit of detection and voltammetric detection sensitivity are derived from the experimental data. Developed methodology was used to detect nitrazepam in pharmaceutical formulation and both drugs (nitrazepam and 7-aminonitrazepam) in spiked biological fluids (urine and blood).