A deprescription program among elderly patients was recently shown to reduce the risk of death by 38%. [British Journal Pharmacology April 14, 2016] For comparison, statin drugs reduce the risk of mortality from heart disease by around 3% compared to taking an inactive placebo pill. [NY Times Feb 9, 2008]
The term deprescribe first showed up in the medical literature around 2007. [Bulletin Academy National Medicine Feb 2007]
Since then numerous reports have been written about the idea of doctors actually reducing Rx medication use or even taking patients off drugs altogether.
The case of a 76-year old woman admitted to the hospital for investigation of fatigue, malaise, emotional instability, muscle weakness, cough and dizziness upon rising from a chair, had been taking 7 medications and had recently completed a course of antibiotics. A diagnosis of adverse drug reactions was made and all medications were withdrawn. Her symptoms gradually resolved on their own.
Reviewers of this case said: “Adverse drug reactions are a common cause of avoidable hospital admissions in the elderly, estimated to cost billions every year. The single greatest risk factor for adverse drug reactions is the number of medications a person takes. Deprescribing to reduce potentially inappropriate medication is a possible way forward.” [BMJ Case Reports May 14, 2015]
The problem of overmedication, also called polypharmacy, has grown in a medical culture where patients are presumed to have a drug deficiency. How do you introduce a deprescription program into a culture of medication?
Just look at the horrendous medication mess reviewers found when they examined the records of just 40 veterans age 65 and older. Here is what they found:
Inappropriate medications 23/40 58% Compliance problems (mental impairment) 10/40 25% Potential overtreatment of high blood pressure 20/40 50% Potential overtreatment of diabetes 17/40 43% Inappropriate dosing excreted drugs 2/40 5% Patient-reported adverse reactions 2/40 5% [Pharmacotherapy June 2016]
Can drugs by safely deprescribed?
There is expressed concern that medication deprescription programs lack randomized controlled studies as evidence for their safety and effectiveness. [Journal American College Cardiology Sept 2016] But these drugs were never studied in combination, only individually. For example, there is no long-term study of patients with heart disease taking a combined regimen of aspirin, statin cholesterol-lowering drugs, blood thinners and beta-blockers and ACE inhibitors to control blood pressure, which commonly occurs.
In Australia, a deprescription program was conducted among 95 residents in aged care facilities. Their mean age was 84 years and they averaged 9.5 medications each. A deprescription program modestly reduced medication by about 2 medications per resident and did not increase mortality. [PLoS One March 4, 2016]
Statin drugs overprescribed
Statin drugs tend to be a throw in, another drug prescribed after all the other drugs are scripted. Many older adults in the last days of their life are taking statin drugs for no purpose whatsoever. They will not die of cardiovascular disease but from other causes. [Journal Palliative Medicine 2008]
Statin drugs have been so boldly prescribed and claimed to save lives that a study had to be undertaken to see if older patients would be willing to cease taking them given there is no evidence they are beneficial in older age. Surprisingly, 89% of patients surveyed said they would be willing to withdraw from the use of statins and 94% said they were always concerned about the side effects of statins anyway. [International Journal Clinical Pharmacology Oct 2015]
Origin of the problem
A report published in a Canadian medical journal described the origin of the problem of overmedication. Overlapping clinical guidelines, often written with the aid of drug companies, end up with elderly patients taking a bag full of drugs prescribed by different physicians and the patient is unsure of why they are taking them. [Canadian Family Physician Dec 2013]
The size of the problem
If one drug is good, more is better, right? Finding a senior American who isn’t taking a prescription drug is a difficult task.
Almost 4 in 10 seniors (39%) take 5 drugs or more. [LA Times Nov 3, 2015] With about 45 million senior citizens, that means 17,550,000 senior Americans are taking 5 or more prescription drugs.
In 2009 63% of Canadian seniors were taking more than 5 medications and 30% of those older than 85 years of age were taking more than 10 medications. Overmedication often results in mental confusion, delirium, falls and hip fractures that result in avoidable hospitalizations. [Canadian Family Physician Dec 2013]
One published report says patients referred to a medication reviewer are typically taking 15 medications per day and have an average of 9 drug-related health problems! [Canadian Family Physician 2011]
Don’t anticipate a rapid change of prescribing habits among physicians. The problem of overprescription of antibiotics was addressed as early as 1978 but little was done about it till now. [US Medicine June 1978]