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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024; 17:637-654. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Coe A, Abid N, Kaylor-Hughes C. Social media group support for antidepressant deprescribing: a mixed-methods survey of patient experiences. Aust J Prim Health 2024; 30:PY23046. [PMID: 38709900 DOI: 10.1071/py23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
Background Antidepressant use has continually increased in recent decades and although they are an effective treatment for moderate-to-severe depression, when there is no longer a clinical benefit, deprescribing should occur. Currently, routine deprescribing is not part of clinical practice and research shows that there has been an increase in antidepressant users seeking informal support online. This small scoping exercise used a mixed-methods online survey to investigate the motives antidepressant users have for joining social media deprescribing support groups, and what elements of the groups are most valuable to them. Methods Thirty members of two antidepressant deprescribing Facebook groups completed an online survey with quantitative and open-text response questions to determine participant characteristics and motivation for group membership. Quantitative data were analysed using descriptive statistics, and open-text responses were analysed thematically through NVivo. Results Two overarching themes were evident: first, clinician expertise , where participants repeatedly reported a perceived lack of skills around deprescribing by their clinician, not being included in shared decision-making about their treatment, and symptoms of withdrawal during deprescribing going unaddressed. Motivated by the lack of clinical support, peer support developed as the second theme. Here, people sought help online where they received education, knowledge sharing and lived experience guidance for tapering. The Facebook groups also provided validation and peer support, which motivated people to continue engaging with the group. Conclusions Antidepressant users who wish to cease their medication are increasingly subscribing to specialised online support groups due to the lack of information and support from clinicians. This study highlights the ongoing need for such support groups. Improved clinician understanding about the complexities of antidepressant deprescribing is needed to enable them to effectively engage in shared decision-making with their patients.
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Affiliation(s)
- Amy Coe
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
| | - Noor Abid
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
| | - Catherine Kaylor-Hughes
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
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Radcliffe E, Servin R, Cox N, Lim S, Tan QY, Howard C, Sheikh C, Rutter P, Latter S, Lown M, Brad L, Fraser SDS, Bradbury K, Roberts HC, Saucedo AR, Ibrahim K. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatr 2023; 23:591. [PMID: 37743469 PMCID: PMC10519081 DOI: 10.1186/s12877-023-04256-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. METHODS A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. FINDINGS A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with 'quick wins', offering deprescribing as 'drug holidays', and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. CONCLUSION We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.
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Affiliation(s)
- Eloise Radcliffe
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK.
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK.
| | - Renée Servin
- Faculty of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Natalie Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Stephen Lim
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Qian Yue Tan
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Clare Howard
- Wessex Academic Health Science Network, Science Park, Chilworth, Southampton, UK
| | - Claire Sheikh
- Hampshire and Isle of Wight Integrated Care Board, Southampton, UK
| | - Paul Rutter
- School of Pharmacy and Biomedical Sciences, Portsmouth University, Portsmouth, UK
| | - Sue Latter
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Mark Lown
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Lawrence Brad
- Westbourne Medical Centre, Westbourne, Bournemouth, UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton Foundation Trust, Southampton, UK
| | - Katherine Bradbury
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- School of Psychology, University of Southampton, Southampton, UK
| | - Helen C Roberts
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton Foundation Trust, Southampton, UK
| | - Alejandra Recio Saucedo
- School of Healthcare Enterprise and Innovation, Trials and Studies Coordinating Centre, National Institute of Health Research Evaluation, University of Southampton, Southampton, UK
| | - Kinda Ibrahim
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
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Huijbers MJ, Wentink C, Lucassen PL, Kramers C, Akkermans R, Spijker J, Speckens AE. Supporting antidepressant discontinuation using mindfulness plus monitoring versus monitoring alone: A cluster randomized trial in general practice. PLoS One 2023; 18:e0290965. [PMID: 37669281 PMCID: PMC10479886 DOI: 10.1371/journal.pone.0290965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 08/17/2023] [Indexed: 09/07/2023] Open
Abstract
Discontinuing antidepressant medication (ADM) can be challenging for patients and clinicians. In the current study we investigated if Mindfulness-Based Cognitive Therapy (MBCT) added to supported protocolized discontinuation (SPD) is more effective than SPD alone to help patients discontinue ADM. This study describes a prospective, cluster-randomized controlled trial (completed). From 151 invited primary care practices in the Netherlands, 36 (24%) were willing to participate and randomly allocated to SPD+MBCT (k = 20) or SPD (k = 16). Adults using ADM > 9 months were invited by GPs to discuss tapering, followed by either MBCT+SPD, or SPD alone. Exclusion criteria included current psychiatric treatment; substance use disorder; non-psychiatric indication for ADM; attended MBCT within past 5 years; cognitive barriers. From the approximately 3000 invited patients, 276 responded, 119 participated in the interventions and 92 completed all assessments. All patients were offered a decision aid and a personalized tapering schedule (with GP). MBCT consisted of eight group sessions of 2.5 hours and one full day of practice. SPD was optional and consisted of consultations with a mental health assistant. Patients were assessed at baseline and 6, 9 and 12 months follow-up, non-blinded. In line with our protocol, primary outcome was full discontinuation of ADM within 6 months. Secondary outcomes were depression, anxiety, withdrawal symptoms, rumination, well-being, mindfulness skills, and self-compassion. Patients allocated to SPD + MBCT (n = 73) were not significantly more successful in discontinuing (44%) than those allocated to SPD (n = 46; 33%), OR 1.60, 95% CI 0.73 to 3.49, p = .24, number needed to treat = 9. Only 20/73 allocated to MBCT (27%) completed MBCT. No serious adverse events were reported. In conclusion, we were unable to demonstrate a significant benefit of adding MBCT to SPD to support discontinuation in general practice. Actual participation in patient-tailored interventions was low, both for practices and for patients. (Trial registration: ClinicalTrials.gov PRS ID: NCT03361514 registered December 2017).
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Affiliation(s)
- Marloes J. Huijbers
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carolien Wentink
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter L.B.J. Lucassen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinier Akkermans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Spijker
- Expertise Centre for Depression, Pro Persona Nijmegen, Nijmegen, The Netherlands
| | - Anne E.M. Speckens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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Omuya H, Nickel C, Wilson P, Chewning B. A systematic review of randomised-controlled trials on deprescribing outcomes in older adults with polypharmacy. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7156969. [PMID: 37155330 DOI: 10.1093/ijpp/riad025] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 04/07/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Mixed findings about deprescribing impact have emerged from varied study designs, interventions, outcome measures and targeting sub-categories of medications or morbidities. This systematic review controls for study design by reviewing randomised-controlled trials (RCTs) of deprescribing interventions using comprehensive medication profiles. The goal is to provide a synthesis of interventions and patient outcomes to inform healthcare providers and policy makers about deprescribing effectiveness. OBJECTIVES This systematic review aims to (1) review RCT deprescribing studies focusing on complete medication reviews of older adults with polypharmacy across all health settings, (2) map patients' clinical and economic outcomes against intervention and implementation strategies and (3) inform research agendas based on observed benefits and best practices. METHODS The PRISMA framework for systematic reviews was followed. Databases used were EBSCO Medline, PubMed, Cochrane Library, Scopus and Web of Science. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised trials. RESULTS Fourteen articles were included. Interventions varied in setting, preparation, use of interdisciplinary teams, validated guidelines and tools, patient-centredness and implementation strategy. Thirteen studies (92.9%) found deprescribing interventions reduced the number of drugs and/or doses taken. No studies found threats to patient safety in terms of primary outcomes including morbidity, hospitalisations, emergency room use and falls. Four of five studies identifying health quality of life as a primary outcome found significant effects associated with deprescribing. Both studies with cost as their primary outcome found significant effects as did two with cost as a secondary outcome. Studies did not systematically study how intervention components influenced deprescribing impact. To explore this gap, this review mapped studies' primary outcomes to deprescribing intervention components using the Consolidated Framework for Implementation Research. Five studies had significant, positive primary outcomes related to health-related quality of life (HRQOL), cost and/or hospitalisation, with four reporting patient-centred elements in their intervention. CONCLUSIONS RCT primary outcomes found deprescribing is safe and reduces drug number or dose. Five RCTs found a significant deprescribing impact on HRQOL, cost or hospitalisation. Important future research agendas include analysing (1) understudied outcomes like cost, and (2) intervention and implementation components that enhance effectiveness, such as patient-centred elements.
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Affiliation(s)
- Helen Omuya
- Health Services Research in Pharmacy, School of Pharmacy, University of Wisconsin Madison, Madison WI
| | - Clara Nickel
- School of Pharmacy, University of Wisconsin Madison, Madison WI
| | - Paije Wilson
- Ebling Library for the Health Sciences, University of Wisconsin Madison, Madison, WI, USA
| | - Betty Chewning
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin, Madison, WI, USA
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Basger BJ, Moles RJ, Chen TF. Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service. BMC Geriatr 2023; 23:183. [PMID: 36991378 PMCID: PMC10061906 DOI: 10.1186/s12877-023-03921-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process. OBJECTIVES To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers. METHOD An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge. RESULTS Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed. CONCLUSION Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .
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Affiliation(s)
- Benjamin Joseph Basger
- Discipline of Pharmacy Practice, Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Room N517, A15 Science Road, Camperdown, Sydney, NSW, 2006, Australia.
- Wolper Jewish Hospital, 8 Trelawney Street, Woollahra, Sydney, NSW, 2025, Australia.
| | - Rebekah Jane Moles
- Discipline of Pharmacy Practice, Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Room N517, A15 Science Road, Camperdown, Sydney, NSW, 2006, Australia
| | - Timothy Frank Chen
- Discipline of Pharmacy Practice, Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Room N517, A15 Science Road, Camperdown, Sydney, NSW, 2006, Australia
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Self-reported reasons for reducing or stopping antidepressant medications in primary care: thematic analysis of the diamond longitudinal study. Prim Health Care Res Dev 2023; 24:e16. [PMID: 36843079 PMCID: PMC9972355 DOI: 10.1017/s1463423623000038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Current treatment guidelines advise that the deprescribing of antidepressants should occur around 6 months post-remission of symptoms. However, this is not routinely occurring in clinical practice, with between 30% and 50% of antidepressant users potentially continuing treatment with no clinical benefit. To support patients to deprescribe antidepressant treatment when clinically appropriate, it is important to understand what is important to patients when making the decision to reduce or cease antidepressants in a naturalistic setting. AIM The current study aimed to describe the self-reported reasons primary care patients have for reducing or stopping their antidepressant medication. METHODS Three hundred and seven participants in the diamond longitudinal study reported taking an SSRI/SNRI over the life of the study. Of the 307, 179 reported stopping or tapering their antidepressant during computer-assisted telephone interviews and provided a reason for doing so. A collective case study approach was used to collate the reasons for stopping or tapering. FINDINGS Reflexive thematic analysis of patient-reported factors revealed five overarching themes; 1. Depression; 2. Medication; 3. Healthcare system; 4. Psychosocial, and; 5. Financial. These findings are used to inform suggestions for the development and implementation of antidepressant deprescribing discussions in clinical practice.
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Zhang Y, Wilkins JM, Bessette LG, York C, Wong V, Lin KJ. Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization. JAMA Netw Open 2023; 6:e230063. [PMID: 36800180 PMCID: PMC9938426 DOI: 10.1001/jamanetworkopen.2023.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
Importance There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults. Objective To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults. Design, Setting, and Participants This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022. Exposures New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc). Main Outcomes and Measures The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used. Results Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs. Conclusions and Relevance The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.
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Affiliation(s)
- Yichi Zhang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent Wong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Lee HY, Lee KS. Withdrawal of antihypertensive medication in young to middle-aged adults: a prospective, single-group, intervention study. Clin Hypertens 2023; 29:1. [PMID: 36593518 PMCID: PMC9806446 DOI: 10.1186/s40885-022-00225-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although antihypertensive drug therapy is commonly believed to be a life-long therapy, several recent guidelines have suggested that antihypertensive medications can be gradually reduced or discontinued for some patients whose blood pressure (BP) is well-controlled for an extended period. Thus, this pilot study aimed to describe the success rate of antihypertensive drug discontinuation over 6 months among young and middle-aged patients with hypertension. METHODS This was a prospective, single-group, intervention study. Patients were eligible for inclusion if their cardiologist judged them to be appropriate candidates for this study, their BP had been controlled both in the office (< 140/90 mmHg) and 24-h ambulatory BP monitoring (< 135/85 mmHg) for at least 6 months with a single tablet dose of antihypertensive medication. A total of 16 patients withdrew their antihypertensive medications at baseline after they received the education, and were followed up over 6 months. After the follow-ups, six patients participated in the in-depth interview. RESULTS The likelihood of remaining normotensive at 30, 90, 180, and 195 days was 1.00, 0.85, 0.51, and 0.28, respectively. There were also no significant differences in baseline characteristics and self-care activities over time between normotensive (n = 8) and hypertensive groups (n = 8). In the interview, most patients expressed ambivalent feelings toward stopping medications. Psychological distress (e.g., anxiety) was the primary reason for withdrawal from this study although the patients' BP was under control. CONCLUSIONS We found that only a limited portion of antihypertensive patients could stop their medication successively over 6 months. Although we could not identify factors associated with success in maintaining BP over 6 months, we believe that careful selection of eligible patients may increase success in stopping antihypertensive medications. Also, continuous emotional support might be essential in maintaining patients' off-medication.
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Affiliation(s)
- Hae-Young Lee
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyoung Suk Lee
- grid.31501.360000 0004 0470 5905Research Institute of Nursing Science, Center for Human-Caring Nurse Leaders for the Future by Brain Korea 21 (BK 21) Four Project, Seoul National University College of Nursing, Seoul, Republic of Korea
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Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population. Geriatrics (Basel) 2022; 7:geriatrics7050097. [PMID: 36136806 PMCID: PMC9498769 DOI: 10.3390/geriatrics7050097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.
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Bachmann P, Frahm N, Debus JL, Mashhadiakbar P, Langhorst SE, Streckenbach B, Baldt J, Heidler F, Hecker M, Zettl UK. Prevalence and Severity of Potential Drug–Drug Interactions in Patients with Multiple Sclerosis with and without Polypharmacy. Pharmaceutics 2022; 14:pharmaceutics14030592. [PMID: 35335968 PMCID: PMC8949310 DOI: 10.3390/pharmaceutics14030592] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 02/01/2023] Open
Abstract
Polypharmacy (PP) is a common problem in modern medicine, especially known to affect patients with chronic diseases such as multiple sclerosis (MS). With an increasing number of drugs taken, the risk of potential drug–drug interactions (pDDIs) is rising. This study aims to assess the prevalence and clinical relevance of polypharmacy and pDDIs in patients with MS. Pharmacological data of 627 patients with MS were entered into two drug–drug-interaction databases to determine the number and severity of pDDIs for each patient. The patients were divided into those with and without PP (total PP and prescription medication PP (Rx PP)). Of the 627 patients included, 53.3% and 38.6% had total PP and Rx PP, respectively. On average, every patient took 5.3 drugs. Of all patients, 63.8% had at least one pDDI with a mean of 4.6 pDDIs per patient. Less than 4% of all pDDIs were moderately severe or severe. Medication schedules should be checked for inappropriate medication and for possible interacting drugs to prevent pDDIs. Physicians as well as pharmacists should be more sensitive towards the relevance of pDDIs and know how they can be detected and avoided.
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Affiliation(s)
- Paula Bachmann
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
- Correspondence: ; Tel.: +49-3814949517
| | - Niklas Frahm
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
| | - Jane Louisa Debus
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
| | - Pegah Mashhadiakbar
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
| | - Silvan Elias Langhorst
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
| | - Barbara Streckenbach
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
- Ecumenic Hainich Hospital Mühlhausen, Pfafferode 102, 99974 Mühlhausen, Germany;
| | - Julia Baldt
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
- Ecumenic Hainich Hospital Mühlhausen, Pfafferode 102, 99974 Mühlhausen, Germany;
| | - Felicita Heidler
- Ecumenic Hainich Hospital Mühlhausen, Pfafferode 102, 99974 Mühlhausen, Germany;
| | - Michael Hecker
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
| | - Uwe Klaus Zettl
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (J.L.D.); (P.M.); (S.E.L.); (B.S.); (J.B.); (M.H.); (U.K.Z.)
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