American Society of Consultant Pharmacists
View all recommendations from this societyReleased May 17, 2021
Don’t continue medications at transitions of care without a pharmacist or other qualified health care professional performing a comprehensive medication review to verify accurate and complete medication information in concert with current medical problems.
Transitions of care can contribute to serious medication-related problems when transitioning between different care settings. Older adults with complex health care problems appear to be a group particularly at risk for increased adverse events. To mitigate errors in prescribing and transcribing, routine assessments should include a comprehensive medication review, medication reconciliation, and an accurate medication history with the patient and his or her advocate. A thorough medication history involves following a systematic process of interviewing the patient, family or caregiver and verifying the history with at least one other reliable source of information to determine the complete and correct list of the patient’s actual medication use at the time of the transition. Negative outcomes associated with transitions across healthcare settings include increased likelihood of polypharmacy when medications are continued that are no longer indicated, therapeutic drug duplication, heightened risk of adverse drug reactions, and poor adherence related to greater complexity of the medication regimen.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
(1–5)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis is on older adults no matter where they reside in step with ASCP’s mission.
Definition wise, deprescribing is a stepwise reduction of unnecessary or potentially inappropriate medications in concert with patient and family goals and wishes. We recognize that even with the best of intentions, many older adults are left on unnecessary and potentially dangerous or duplicative medications that might precipitate adverse events and other negative outcomes.
The task force prioritized formulation of the Choosing Wisely (CW) List, since the goals of CW intersect and overlap with deprescribing initiatives. The list was created to address general medication regimen review statements, and more importantly to address the paucity of statements that address DDIs with several incriminating medication therapeutic classes prescribed for older adults. After a review of published CW statements on www.choosingwisely.org and also a review of CW statements published by international countries, it was decided by consensus to have a strong emphasis on DDIs.
After several virtual meetings, the CW workgroup was divided into subgroups to formulate DDIs that have a strong evidence base in the literature and those that focus on CNS therapeutic classes, anticholinergic burden, heightened bleeding risk, and other pivotal pharmacokinetic and pharmacodynamic DDIs. For each statement the group formulated a rationale that was evidence-based accompanied with several recent, pertinent references. The compiled list (after several virtual meetings and email discussion) was further reduced to top ten statements with the strongest evidence base and practice trends on medication management in older adults.
The top five list was selected by consensus for initial submission.
Attached is a recently published guest editorial in ASCP’s journal that highlights the emphasis on DDIs.
Beier MT. Vigilance of Drug-Drug Interactions to Mitigate ADRs: Front and Center for Pharmacists (Guest Editorial). Sr Care Pharm 2020; 35:336-7.
(6–10)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis for all our statements is on older adults no matter where they reside in step with ASCP’s mission. Our first 5 CW statements were published in May 2021.
As previously addressed, the rationale for the new 2022 list (statements 6–10) includes one medication review statement in older adults with limited life expectancy, and three statements emphasizing the adverse combination of CNS medications that have a strong evidence base in the literature including tramadol’s potential for greater harm than benefit for pain relief, especially in older adults. We had previously highlighted pharmacodynamic DDIs for heightened bleeding risk, and this time our statement addresses the complexity of pharmacokinetic DDIs with Direct Oral Anticoagulants (DOACs).
Sources
Davies EA, O’Mahony MS. Adverse drug reactions in special populations – the elderly. Br J Clin Pharmacol 2015;80(4):796-807.
Weir DL, Lee TC, McDonald EG, Motulsky A, Abrahamowicz M, Morgan S, et al. Both new and chronic potentially inappropriate medications continued at hospital discharge are associated with increased risk
of adverse events. J Am Geriatr Soc 2020;68(6):1184-1192.
De Oliveira GS Jr, Castro-Alves LJ, Kendall MC, McCarthy R. Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization After Transitions of Care: A Meta-analysis
of Randomized Controlled Trials. Journal of Patient Safety. 2017 Jun.
Janice L. Kwan, Lisha Lo, Margaret Sampson, et al. Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review. Ann Intern Med.2013;158:397-403.
Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized
Clinical Trial. JAMA. 2018;320(18):1889–1898.
Stranges PM, Jackevicius CA, Anderson JL, Bondi DS, Danelich I, Emmons RP, et al. ACCP White Paper: Role of clinical pharmacists and pharmacy support personnel in transitions of care. J Am Coll Clin Pharm
2020;3(2):532-545.
American Society of Consultant Pharmacists. Pharmacist Role in Transitions of Care. Consult Pharm 2017;32:645-9.
