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Erschienen in:
14.05.2020 | Viewpoint
Implementing a Proactive Deprescribing Approach to Prevent Adverse Drug Events
Erschienen in: Journal of General Internal Medicine | Ausgabe 12/2020
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Adverse drug events (ADEs) are a leading cause of preventable harm in the USA. The majority of ADEs are experienced by older adults and are most commonly related to medications taken for chronic conditions (e.g., anticoagulants, hypoglycemics, and analgesics).1 After an ADE occurs, the complicit medication is usually discontinued—a process we term reactive deprescribing. While necessary, reactive deprescribing is not sufficient to optimize patient safety and wellbeing. To move beyond reacting to ADEs and instead prevent them, widespread adoption of proactive deprescribing, whereby thorough review and routine reconsideration of the risks and benefits of chronic medications are incorporated into clinical care, is needed (Table 1). Despite a growing evidence base including observational studies2 and randomized trials3 increasing physician awareness of deprescribing, implementation of proactive deprescribing in the US healthcare system faces structural challenges related to reimbursement, time, and communication. We believe that overcoming these challenges can be achieved by building upon existing Medicare programs to provide a venue to implement proactive deprescribing in a reimbursable and sustainable fashion.
Table 1
Comparison of Reactive and Proactive Deprescribing
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Reactive deprescribing
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Proactive deprescribing
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|---|---|---|
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Definition
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Aims to minimize ongoing harms once a patient experiences new medication-related harm or symptom
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Aims to prevent the onset of an acute medication-related harm or symptom
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Triggering event
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New symptom
- Medication-related harm or symptoms suspected to be related to medication, prescribing cascade, or drug interactions
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Routine part of care
- Annually for all adults taking ≥ 5 chronic medications; more frequently for those taking ≥ 10 chronic medications
- Following a new chronic disease diagnosis, major change in physical or cognitive function, or change in goals of care
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Setting
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Acute setting: hospital, ED, or acute clinic visit
- Directed by treating provider who may not have existing relationship with patient
- Requires communication between acute care provider and long-term care team members
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Outpatient setting
- Directed by primary care clinic: physician, pharmacist, nurse practitioner, physician assistant
- Requires communication between primary and specialty care team members
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Example
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Mrs. F is a 73-year-old female with depression, diabetes with hemoglobin A1c of 7.0%, and recently diagnosed congestive heart failure, NYHA functional class 1, who takes 7 chronic medications
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She presents to the ED with confusion and is found to have a blood glucose of 40 mg/dL. She is treated with glucagon and intravenous dextrose and admitted for observation
She is monitored overnight and at discharge is instructed to stop her glipizide and continue taking metformin and pioglitazone
Hospital follow-up is scheduled with her PCP within 2 weeks
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As part of an MTM visit, the pharmacist initiates a deprescribing discussion given her polypharmacy and multiple chronic conditions. The pharmacist contacts her by phone to reconcile her medications and contacts her cardiologist and PCP to coordinate optimizing her medications
As her hemoglobin A1c is at goal and she has been successful with diet changes, the team recommends continuing metformin and stopping her glipizide (given risk of hypoglycemia) and pioglitazone (given risk of worsening heart failure)
She presents to her primary care clinic for routine care, and her PCP discusses these recommendations. She agrees with this plan and schedules follow-up in 3 months to monitor her diabetes and in 1 year for routine health maintenance including a deprescribing discussion
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