TaperingMedications–TheWho,What,When,Where,Why,andHow

September30,2017Fredericton,NewBrunswick

ZackDumontClinicalSupportPharmacist– RQHRDepartmentofPharmacyServicesClinicalPharmacist– RxFiles AcademicDetailingProgramMedicationConsultant– medSask MedicationInformationService

Faculty/PresenterDisclosure

• Faculty:ZackDumont

• Currentorpastrelationshipswithcommercialinterests– AdvisoryBoard/SpeakersBureau:nil– Funding(Grants/Honoraria):nil– Research/ClinicalTrials:nil– Speaker/ConsultingFees:nil– Other:nil

• SpeakingFeesforcurrentprogram– Ihavereceivednospeaker’sfeeforthislearningactivity

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DisclosureofCommercialSupport

• Thispresentationhasnotreceivedfinancialsupportfromanyorganization

• Thispresentationhasnotreceivedin-kindsupportfromanyorganization

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MitigatingPotentialBias

• Notapplicable

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Geri-RxFiles 2nd Edition

• Atooltosupporthealthcareprofessionalsinoptimizingmedicationuseinolderadultsby– Identifyingmedicationsthatmaybecausingmoreharmthanbenefit

– Providinganapproachtoassessmentofvariousconditionsandassociatedmedications

– Comparingthevariousalternatives inordertoensurepatients/residentsarereceivingthemostappropriatetreatmentpossible

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Geri-RxFilesDevelopment

• Criticallyevaluatedtheliteratureand(limited)availableevidence

• SynthesizedinformationfromBeersCriteria&STOPPtools(andbeyond!)

• ConsideredCanadianguidelinerecommendations• Consultedwithgeriatricians,familyphysicians,nurses,andpharmacists insortingthroughpotentiallypreferredoptions– practicalexperience

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Geri-RxFiles 2nd Edition

• Covers22conditions• Eg,Constipation,COPD,Depression,DrugInteractions,ElectrolyteImbalance,FallsPrevention,Nutrition/Supplements,MedicationAdministrationChallenges:“CrushList”(pg,143)

• Othergreattools– Eg,COPDInhalerTechnique (pg, 128)

• Incorporatedtheupdated2015BeersCriteriaandtheupdated2014STOPP/STARTCriteria

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Geri-RxFiles 2nd Edition• TableofContents• TherapeuticTopics

FirstSection:– Step-wiseapproachtoassessingadisease,includingpotential

contributorssuchasothermedicalconditionsormedications– Non-pharmacologicaloptions– MedicationtreatmentoptionsSecondSection:– Tableofpotentiallyproblematicmedicationusedinthetreatmentof

disease/condition– IndicationofwhethermedicationappearsoneithertheBeersor

STOPPCriteria,inwhothemedicationsareproblematic,andotherclinicalconcerns

• TaperingMedications

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LearningObjectives

• Participantswillbeableto:– Useavailableresources fortaperinganddeprescribing medications

– Describesituationswhentaperingmedicationsissupportedbyevidenceandliterature

– Constructaplanwhenevidenceorguidancefor taperingmedications islessclear

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Wherearewegoing?

• “Itisanartofnolittleimportancetoadministermedicinesproperly;butitisanartofmuchgreaterandmoredifficultacquisitiontoknowwhentosuspendoraltogetheromitthem.”

– DrPhilippePinel» 1745to1826

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OURGUIDE?

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WHAT(ISBEINGTAPERED?)

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Whatisbeingconsideredfortapering?

• Medications– …butnotjustanymedications.Medicationsthat…

• …thepatienthasbeenonalongtime• …werestartedbecausethebenefitsoutweighedtherisks

• …wereprobablystartedbysomeoneelse• …allworkindifferentways,pharmacokinetically andpharmacodynamically

• …mayormaynotrequiretapering

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Theproblem(s)withtapering

• It’shard…– …toknowinwhom,andhowtheywilltolerateit– …toknowwhywemayneedto– …toknowwhen– …toknowwheretostart– …toknowhow

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PresentationOutline

• Solet’slearn…– …toknowinwhom,andhowtheywilltolerateit– …toknowwhy wemayneedto– …toknowwhen– …toknowwhere tostart– …toknowhow

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• “We’vemasteredaddition,nowit’stimetomoveontosubtraction”

– LorenRegier

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Someobstacleswe’llencounter

• Individualsmayhaveanemotionalattachmenttotheirmedicationsandgainingbuy-inmaybedifficult

• Certainmedicationswilltakealongtimetotaperdown

• Most(all?)prescribingtoolsonlyprovideinformationonhowstartmedications

• Evidence onhowtotaperislackingandislargelyanecdotal– Asaresult,itisconsideredmoreanart thanascience…

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WHO(MAYNEEDATAPER?)

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Whomayneedataper?

• Anyone– Mostcontemporaryfocusisonolderadults(warranted!),butmanyyoungerpatientsarenotwithoutneed

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Whomayneedataper?

• Manycompetingpriorities,sowhoismostlikely?– Thosewithmultiplecomorbidities

• Whichismostlikelyinolderadults,butisnotexclusive

– Thoseonmanymedications– Thosewhohavenotenoughinteractionwiththehealthcaresystem(ie,notenoughfollow-uporreassessment)

– Thosewhohavetoomuchcontactwiththehealthcaresystem(ie,invitingtoomanycooksintothekitchen)

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Whomayneedataper?

• Anyone…– …thatisonmoremedicationsthanclinicallyindicated,orusinginappropriatemedications

• Dowerecognizethisdefinition?

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Whomayneedataper?

• Anyone…– …thathas,orisexperiencing,polypharmacy

• Definitionofpolypharmacy:– Manydefinitions(ie,notonestandarddefinition)

• Eg,Useof“multiple”medicationsbyapatient– Dependingonreference,“multiple”=5to10

• Eg,Moremedicationsthanclinicallyindicated,oruseofinappropriatemedications

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• Polypharmacyusuallymeans…

– …we’regoingtohavetogetridofsomedrugs

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WHY(TAPER?)

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Whytaper?

• Manymedicationsareassociatedwithabruptwithdrawalreactions– Shouldbewithdrawngraduallytominimizethepotentialoftheseadverseeffects,unlesssafetyconcernsrequireamorerapiddiscontinuation

• Inrapiddiscontinuationsituations,beawareofprobablewithdrawaleffects

• Thegoaloftaperingmedicationsistominimizediseasere-occurrence orre-emergence– Eg,depressionwhentaperinganSSRI

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Whytaper?

• Isittostop allpotentiallyunnecessarymedications?– Notnecessarily…

• Ifthemedicationbeingtaperedcannotbediscontinuedcompletely,adecreaseindosemaystillbeconsideredawin!– Onemightnotalwaysbesuccessfulincompletelydiscontinuingamedication,andthat’sokay

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WHEN(TOTAPER?)

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Whentoconsiderataper?

• Asmentioned,whenstoppingmedications– …thosethatareoverused– …thoseinwhichtherisksoutweighthebenefits– …thosewheresaferalternatives areavailable

• Inotherwords…– …anytimeyouplanondeprescribing (orsupportinganotherintheirdeprescribing efforts),youneedtoconsiderwhetherataperisneeded

• Ruleout ataper3 October 2017 32

Whentoconsiderataper?

• Refresher:– Deprescribing istheplannedprocess (supervised)ofreducingorstoppingmedicationsthatmaynolongerbeofbenefitormaybecausingharm

• Thegoalistoreducemedicationburdenorharmwhileimprovingqualityoflife(credit:deprescribing.org)

– It’smorethanjuststoppingmeds… it’saplanwithina(care)plan

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Whentoconsiderataper?

• Overly-simplified,butstillsomewhatusefulruleofthumbfordecidingtotaperornot:– Ifagradualdoseincrease(ie,titration)wasrequiredwhenthemedicationwasinitiated,itisreasonabletoassumethatthedoseshouldbegraduallydecreasedupondiscontinuation

• Needfortitrationprobablycorrelatestoaneedfortapering

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Whentoconsiderataper?

• Anotherbarrier:– Diseasereconciliation

• Determiningifamedicationisstillindicated=difficultwhenacompletemedicalhistoryisnotavailable

– Eg,onadmissiontoalong-termcarehome

– Often,theonlywaytodeterminewhetheramedicationisstillneededorwhetherthedoseremainsappropriateistotryataper

• Lowerthedoseandmonitorforimprovement,stabilization,ordecline

• “Ifindoubt,ataperissafer”– Apracticalguidetostoppingmedications(BPJ;Issue27;bpac.org.nz)

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WhentoNOT taper?

• Drug-inducedtoxicity– Juststop,thenmakeaplan

• Questionstoask– Canwemonitorlevels?– Willtheygetwithdrawalonceonthesubtherapeutic side ofthetherapeuticwindow?

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WHERE(TOSTARTTAPERING?)

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Wheretostarttapering?

• Lookforeasywins– Medicationswithlimitedbenefitsand/orhighrisksofharm

– Eg,antipsychoticsusedforthebehavioursofdementia,somebeta-blockers,benzodiazepines,andprotonpumpinhibitors

– Medicationsthatyourpatientsareaskingabout– “5Questionstoaskaboutyourmedications”campaign

• Arethereanysupportingtoolsorstrategiesoutthereforthosedrugs?Whatresourcesmightyoucheck?Moreonthisshortly…

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Wheretostarttapering?

• Lookforeasywins– Wherethereisliteraturetosupportthetaperingprocess

• Butit’snotalwayseasy… thehardcaseswillcome… theyalwaysdo– Weneedaplan(we’regettingthere… thankyouforyourpatience)

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HOW(TOTAPER?)

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Howtotaper?

Step1–identifymedication(s)tobediscontinued

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Howtotaper?

• Asdiscussed,toidentifythedrugstobetaperedconsiderabove(ie,what,who,when,where)

• Alsoconsider:– Whatisthisspecificmedicationdoingforthisspecificindividual– clinicallyandpersonally?

– Isitkeepingtheindividualwell andimprovingday-to-dayqualityoflife,orisitbeingusedforthepreventionofillness inthefuture?

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Howtotaper?

Step2–createadeprescribingplan• Keyquestion:

Doesthemedication(s)needtobetapered?(mustruleout)

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Howtotaper?

• Somanyfactorstoconsider– Themedication’shalf-life– Themedication’smechanismofaction

– Arereceptorsinvolved?Couldtherebeup-regulation/down-regulation?

– Arebiochemicalpathwaysinvolved?Couldcompensatorymechanismsbeactivated?Negativefeedbackloopsactivated?

– The(?)condition’spathophysiology– The(?)condition’sconsequence(s)– Thepatient’sfragility/strength– Thepatient’sgoalsandwishes

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Howtotaper?

• Otherfactorstoconsider– Beforewegocreatingourownplan,let’scheckforexistingevidence/literaturetosupportthetaper

• Deprescribing.org algorithms• Geri-RxFiles• Primaryliterature(potentiallytime-consuming)• (ie,step3)

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Howtotaper?

Step3–checkavailableresourcesforataperingregimen

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Deprescribing.org

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Deprescribing.org

• Currentlyavailabledeprescribing algorithmsandwhiteboards– ProtonPumpInhibitor– Benzodiazepine receptoragonist– Antipsychotic– Antihyperglycemic– Morecoming

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Geri-RxFiles

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Geri-RxFiles 2nd Edition• TableofContents• TherapeuticTopics

FirstSection:– Step-wiseapproachtoassessingadisease,includingpotential

contributorssuchasothermedicalconditionsormedications– Non-pharmacologicaloptions– MedicationtreatmentoptionsSecondSection:– Tableofpotentiallyproblematicmedicationusedinthetreatmentof

disease/condition– IndicationofwhethermedicationappearsoneithertheBeersor

STOPPCriteria,inwhothemedicationsareproblematic,andotherclinicalconcerns

• TaperingMedications

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Geri-RxFiles2ndEdition• Specificmedicationtaperingsection

– Anticholinergics– Anticonvulsants– Antidepressants– Antihistamines– Anti-Parkinson’s– Antipsychotics– Beta-blockers,clonidine– Benzodiazepinesand‘z’drugs– Corticosteroids– Nitrates– Opioids– Protonpumpinhibitors– Andmore

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PrimaryLiterature

• Somedoesexist– Eg,ThompsonW,Hogel M,LiY,Thavorn K,O’DonnellD,McCarthyL,Dolovich L,BlackC,FarrellB. Effectofaprotonpumpinhibitordeprescribing guidelineondrugusageandcostsinlong-termcare.JAMDA,2016;17(7),673.e1–673.e4

• Canbechallengingtotrackdownforbusyclinicians– Timepermitting(ie,ifnorushforthepatient…),useyourteam

• Eg,druginfoservices,librarians,etc

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Howtotaper?

Step4–ifnoresourcesexist,createataperingregimen

(…simple,right?)

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InspirationalQuote

• “Thecodeismorewhatyoucallguidelines,thanactualrules”

-CaptainBarbossa

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Howtotaper?

• Areasonableapproachtograduallydiscontinuingamedication=decreasethedoseby25%atweekly(orlonger)intervalswithclosemonitoring– Amorecautiousapproachmaybewarrantedincertaincircumstances(eg,highdose,severedisease,long-termuse,interferencewiththehormonalsystem)

– Adjusttherateoftaperbasedonindividualfactors– Bepreparedtoadjusttherateagain,basedonresponse

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Howtotaper?Howmuchto¯ dosebyattheinitialstepoftapering

Speed Situationtoconsidertaperingbythecorrespondingamount

100%(abruptdiscontinuation)

VeryFast

Drug-inducedtoxicity

50% FastNotveryconcernedaboutwithdrawal;individualisrelativelyhealthy/vibrant

25% SlowSomewhatconcernedaboutwithdrawal;individualhasmultiplecomorbidities,butisnotyetveryfrail

5to10% VerySlow

Concernedaboutwithdrawal;individualisquiteillorfrail

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Howtotaper?

• Setexpectations– Timerequiredforthetotaltaperingprocessandresultantdiscontinuation

• DefiningaFAST vsaSLOW taper:– Fast:2to4weekstocomplete– Slow:3to6monthstocomplete

» Eg,estrogens– VerySlow:1to2years

» Eg,benzodiazepines,verylong-termopioids

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Howtotaper?

Step5–implementthetaper

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Howtotaper?

• Whenimplementingataper(evenwhenimplementingknowntaperingregimens),considerfactorsthatmayaltertheapproach:– Urgency/reasonfortaper– Dose ofmedication– Duration ofuse– Indication foruseandbenefitreceived– Patientfactors(eg,age,comorbidities,concomitantmedications,

prescribingcascades,adherence,consequencesofpotentialwithdrawalsymptoms,patient’swishes)

– Dosageforms/strengths availabletofacilitatetaper

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Howtotaper?

• Ifmultiplemedicationsaretobediscontinued– Taperonemedicationatatime(ifpossible)

• Itwillbeeasiertoidentifythelikelycauseifwithdrawalreactionsdooccur

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Howtotaper?

Step6–monitorandreassess,adjustifneeded

PDSA!

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Monitoring&Follow-up

• Pharmacistscanprovideleadership– Educatepatientsandcaregiversaboutanysymptomsforwhichtheyshouldcontacttheirprescriberorseekemergencytreatment

– Reassureandoffersymptommanagementoptionsforothersymptoms

– Slowdown(orrestartthemedication)ifwithdrawalsymptoms orsymptomsoftheconditionbeingtreatedoccurduringthetaperingprocess

• Resumethepreviousdoseandconsideramoregradualtaper

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• Mightsoundcomplicated… butitdoesn’thavetobe

• And…

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Thereishope

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Thereishope

• Evidenceforsafetyandcost-effectivenessismounting

• Eg,EMPOWERstudy(benzodiazepines)– CIHR– Testingtheintervention– P:144patients– I:providedwithbrochure(infoonrisk,how-tostop,etc)– O:45.1%perceivedincreasedriskafterintervention

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Martin P, Ahmed S, Tamblyn R, Tannenbaum C. A drug education tool developed for older adults changes knowledge, beliefs and risk perceptions about inappropriate benzodiazepines in the elderly. Patient Educ Couns. 2013; 92(1):81-7.Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014; 174(6):890-8.

Thereishope

• Evidenceforsafetyandcost-effectivenessismounting

• Eg,EMPOWERstudy(benzodiazepines)– CIHR– Thetrial– Reductionofinappropriatebenzodiazepineprescriptionsamongolderadultsthroughdirectpatienteducation:theEMPOWERclusterrandomizedtrial

– C:Nobrochure(usualcare)– O:At6months27% ofinterventiongrouphadstoppedBZDs(vs5%incontrolgroup);riskdiff23%(95%CI14to32%)

– Inotherwords… more‘how-to’coming

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Martin P, Ahmed S, Tamblyn R, Tannenbaum C. A drug education tool developed for older adults changes knowledge, beliefs and risk perceptions about inappropriate benzodiazepines in the elderly. Patient Educ Couns. 2013; 92(1):81-7.Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014; 174(6):890-8.

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Thereishope

• D-PRESCRIBEtrialcoming(expectedin2017)• TheCanadianPrimaryCareSentinelSurveillanceNetworkSeniorsDeprescribing Trial(expectedin2018)

• Geriatricpharmacoeconomics (ongoingstudies)• CaDeN – CanadianDeprescribing Network

– Membersrepresentawiderangeofperspectivesrelatedtodeprescribing,includingpatientadvocates,healthcareprofessionals,academicresearchers,andotherhealthcareleaderswithexperienceinthepharmaceuticalfield

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CASES

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Case1(Quick)

• HeartFunctionClinic(ambulatory)– SH,68yearoldfemale,lowejectionfraction(EF)heartfailure

– Referredtoclinicduringrecenthospitaladmission– PMHx:CHF(EF23%),HTN

• Bloodpressure(BP)today=105/61

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CurrentMedications:Ramipril10mgpodailyMetoprolol50mgpoBIDFurosemide40mgpoBIDDiltiazem120mg(SR)podailyAtorvastatin40mgpoHS

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SHPMHx:CHF(EF23%),HTNCurrentMedications:Ramipril10mgpodailyMetoprolol50mgpoBIDFurosemide40mgpoBIDDiltiazem120mg(SR)podailyAtorvastatin40mgpoHS

• IfyouweretomakeanychangestoSH’smedications(ie,deprescribe),whatwouldtheybe?

• Howwouldyouprioritizethesemedicationchanges?

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DiltiazeminLowEFHeartFailure

• Worsensheartfailure(canleadtoconductionabnormalitiesandheartblock)– Contraindicated

• Whatwouldyoudo?Taperrequired?– Westoppeditcoldturkey– notaper– Rationale:

• 1)potentiallytoxicdrug• Nottomention:nosimpletaperingregimen

– 120mgislowestslow-releasedose(wouldneedtoswitchto60mgpoBID,but… see1

• 2)patientwasabletomonitorBPandHRathome• 3)itwaspreventingusfromgoingupinotherEBMtherapies(eg,metoprololwasnotoptimized)

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Case2

• FallsAssessmentClinic– DT,78-year-oldmale,previoushipfracturesecondarytofall

• Havingdifficultyathome;movedinwithdaughter’sfamily1monthago

– PMHx:Multiplefalls(hip#3monthsago)– hascanetoambulate,butdoesn’tliketouse,osteoporosis,migraine,hypertension,COPD,insomnia

– Socialhistory:EtOH (1glasswineweeklyonSundays)– Smoking:ex-smoker(quitage37)– Druguse:noillicitdruguse

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Adaptedfrom:J.Lake,PHM652– PrimaryCare,UniversityofToronto

CurrentMedications:(blister-packedbycommunitypharmacy)Nitrazepam 10mgpoqHS +10mgpoqHS prnifdoesn’tsleepHydrochlorothiazide25mgpodailyPerindopril8mgpoBIDAmlodipine10mgpodailyPropranolol40mgpoBIDAtorvastatin40mgpodailyRisedronate 35mgpoweeklyCalcium500mgpodailyVitaminD1000unitspodailyAcetaminophen1gpo30minutesbeforePT+1gpoafterPTifneededSennosides 8.6mg2tabspoqHS prnDocusate100mgpoBIDVitaminB121mgsub-qmonthlyAdvair500Diskus 1puffBIDTiotropium18mcgdailySalbutamol2puffsprn

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DT

ChronicIllness/DisabilityImpactingFallsRisk:1. Cognitiveimpairment– no2. Stroke– no3. Parkinson’sdisease– no4. Insomnia– yes

– Poorhistorianaboutsleepissuesastakesnitrazepam asorderedwhetherdifficultyfallingasleepornot

– Hasbeenonnitrazepam x15yrs (sincesisterdiedinaccident)

5. Cardiacdisease– yes(HTN,nocardiacevents)– BPconsistentlylowathome,testsseveraltimesweeklyandalways

less100/60– Complaintsofdizzinessonstanding,hasfallenbackintochairupon

standinguptowalkathome

6. COPD– no– Well-controlled;noAECOPDinpast24months– Hasnotusedsalbutamolinmorethan6monthsevenwithPT

7. Diabetes– no8. Visualimpairment– no,buthasn’tseenoptometristfor3years9. Osteoporosis– yes

– Recentlydiagnosedattimeofhip#(3monthsago)andstartedrisedronate,calcium,vitaminD– tobereassessedin18months

10. Osteoarthritis– no11. Incontinence– no12. Acuteillness– no

DOB:23-AUG-1936(78yo)PMHx:multiplefalls(hip#3monthsago),osteoporosis,migraine,hypertension,COPD,insomniaCurrentMedications:(blister-packed)Nitrazepam 10mgpoqHS +10mgpoqHSprnifdoesn’tsleepHydrochlorothiazide25mgpodailyPerindopril8mgpoBIDAmlodipine10mgpodailyPropranolol40mgpoBIDAtorvastatin40mgpodailyRisedronate 35mgpoweeklyCalcium500mgpodailyVitaminD1000unitspodailyAcetaminophen1gpo30minutesbeforePT+1gpoafterPTifneededSennosides 8.6mg2tabspoqHS prnDocusate100mgpoBIDVitaminB121mgsub-qmonthlyAdvair500Diskus 1puffBIDTiotropium18mcgdailySalbutamol2puffsprn

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DT

• IfyouweretomakeanychangestoDT’smedications(ie,deprescribe),whatwouldtheybe?

• Howwouldyouprioritizethesemedicationchanges?

DOB:23-AUG-1936(78yo)PMHx:multiplefalls(hip#3monthsago),osteoporosis,migraine,hypertension,COPD,insomniaCurrentMedications:(blister-packed)Nitrazepam 10mgpoqHS +10mgpoqHSprnifdoesn’tsleepHydrochlorothiazide25mgpodailyPerindopril8mgpoBIDAmlodipine10mgpodailyPropranolol40mgpoBIDAtorvastatin40mgpodailyRisedronate 35mgpoweeklyCalcium500mgpodailyVitaminD1000unitspodailyAcetaminophen1gpo30minutesbeforePT+1gpoafterPTifneededSennosides 8.6mg2tabspoqHS prnDocusate100mgpoBIDVitaminB121mgsub-qmonthlyAdvair500Diskus 1puffBIDTiotropium18mcgdailySalbutamol2puffsprn

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NitrazepamUse(FallRisk)

• Initiallyprescribedthismedication10to15yearsagofordifficultysleepingafterhissisterdiedinMVA– Takesregularlywhetherhehasdifficultyfallingasleepornot;feelsit

workswellforhimashehasnodifficultyfallingasleeporstayingasleepwithuse;duetoit’sefficacy,hehasnevertriedanyalternativestohelphimsleep

• Unknownwhetherhetakesanyadditionalprnnitrazepamdosesifhedoesn’tsleep– Unlikelyashestatedthatthescheduleddoseworkswellforhim

• Sometimesfeelssluggishinmorning– Admittedtofeeling“hungover,”nothimself,orextratiredsometimes

whenquestioned

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NitrazepamUse(FallRisk)

• Usualsleepregimenconsistsoftakingnitrazepamdose30minutespriortosleep,reading/watchingTV,thenattemptingsleepat22h00eachnight

• Whatwouldbeareasonableapproachtostoppinghisnitrazepam?– Decreaseby25%/weekx2weeks,then10%/weekthereafter

– Nitrazepam 7.5mgpoqHS x1week,then5mgpoqHS x1week,then2.5mgpoqHS x1week,then2.5mgpoqHSeveryotherdayx1week,thenstop

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Hypotension(FallRisk)

• Patientcomplainsofdizzinessonstanding,andhasfallenbackintochairuponstandinguptowalk

• Propranolol40mgpoBID– Originallyprescribedformigraineprophylaxis;nomigrainesforthe

past5to6years,andwhenhewasexperiencingmigraines,hewouldhave2to3migraines/year

• PatienthasnohistoryofCVDorstroke,butmayhavenewdiagnosisofdiabetes(HbA1C=7.7%),thoughthisrequiresfurtherinvestigation

• Patientstateshedoesnotfollowlowsaltdietforhypertension;daughterpreparesmeals

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Hypotension(FallRisk)

• Whatwouldbeareasonableapproachtostopping/loweringhisBPmedications?– Hydrochlorothiazide25mgpodaily– taper?

• Probablynot

– Perindopril8mgpoBID– taper?• Notusually

– Amlodipine10mgpodaily– taper?• Maybe

– Propranolol40mgpoBID– taper?• Probably– gradually taperthedoseby25to50%every1to2weeks

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LaxativeUse(Polypharmacy)

• Thesewereinitiatedwhenhewasprescribedopioidsforpainmanagementpost-hipfracture3monthsago– Patientisnolongertakingopioidsashippainadequatelycontrolled;

patientratespainas1/10to2/10,but4/10duringphysiotherapysessionswhichhemanagesbytakingacetaminophen

• Patienthasnotbeentakingthesemedicationsashisdietaryfiberintakehasincreasedsincehavinghismealspreparedbyhisdaughter

• Atpresent,patientstateshenormallyhas1bowelmovementdaily,typicallysoft,easytopass,withnopain

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LaxativeUse(Polypharmacy)

• Whatwouldbeareasonableapproachtostoppingsome/allofhisbowelcare?Taperrequired?– Probablynot

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VitaminB12Use(Polypharmacy)

• Initiatedthisonphysicianrecommendationtoimprovehissymptomsoffatigueandlowenergy15yearsagoafterhissisterdiedinMVA– PatientdoesnotrecallbeingdiagnosedwithanemiaorvitaminB12deficiency

• Mostrecentlabvaluesunremarkable:hemoglobin=129g/L,hematocrit=0.37(July28/16);MCV,vitaminB12levelnotdrawn/reported;nootherlabdataavailable

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VitaminB12Use(Polypharmacy)

• Whatwouldbeareasonableapproachtostopping?Taperrequired?– Probablynot

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CONCLUSIONS

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SummaryofTaperingProcess

• Step1– identifymedication(s)tobediscontinued• Step2– createadeprescribing plan

– Keyquestion:Doesthemedication(s)needtobetapered?

• Step3– checkavailableresourcesforataperingregimen

• Step4– ifnoresourcesexist,createataperingregimen

• Step5– implementthetaper• Step6– monitorandreassess,adjustifneeded

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LearningObjectives

• Participantswillbeableto:– Useavailableresourcesfortaperinganddeprescribingmedications

– Describesituationswhentaperingmedicationsissupportedbyevidenceandliterature

– Constructaplanwhenevidenceorguidancefor taperingmedications islessclear

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References• Apracticalguidetostoppingmedications(BPJ;Issue27;bpac.org.nz)• Geri-RxFiles medicationtaperingsections• Deprescribing.org• MartinP,AhmedS,TamblynR,TannenbaumC. Adrugeducationtool

developedforolderadultschangesknowledge,beliefsandriskperceptionsaboutinappropriatebenzodiazepinesintheelderly.PatientEduc Couns.2013;92(1):81-7

• TannenbaumC,MartinP,TamblynR,BenedettiA,AhmedS. Reductionofinappropriatebenzodiazepineprescriptionsamongolderadultsthroughdirectpatienteducation:theEMPOWERclusterrandomizedtrial. JAMAInternMed.2014;174(6):890-8

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Questions?Now• Pleaseshareany

– Questions– Comments– Musings

Later• Contactme

– Email:zackdumont@me.com– Twitter:@ZackDumontYQR– LinkedIn:/ZackDumont

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