Don’t prescribe or routinely continue medications for older adults with limited life expectancy without due consideration to individual goals of care, presence of comorbidities and time-to-benefit for preventive medications.
Older adults with limited life expectancy (life expectancy less than 24 months) continue to be consumers of health care resources, including preventive medications for chronic diseases that provide questionable benefit. At the end of life, consider shifting from curative to palliative goals of therapy with subsequent modifications in medication use with regards to individual’s goals of care. To identify older adults for whom medications are most likely to benefit (and most likely to harm), a framework that compares an individual’s life expectancy with the time to benefit (TTB) has been proposed. TTB may be defined as the point in time at which patients are expected to derive a benefit from a treatment. TTB is increasingly considered in addition to other measures of medication effectiveness to understand and contextualize the benefits and harms of a therapy for an individual patient. Reducing the use of unnecessary medications may reduce pill burden and adverse drug events, as has the potential to improving quality of life.
Some recent studies have highlighted medications to manage dementia (cholinesterase inhibitors and memantine) and possibly statins as medications of questionable benefit for older adults with advanced dementia.
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.
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).
Holmes HM, Min LC, Yee M, et al. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging. 2013;30(9):655-666.
Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decisions for older adults. JAMA. 2013;310(24):2609-2610.
Lee SJ, Kim CM. Individualizing Prevention for Older Adults. J Am Geriatr Soc. 2018;66(2):229-234. Matlow JN, Bronskill SE, Gruneir A, et al. Use of Medications of Questionable Benefit at the End of Life in Nursing Home Residents with Advanced Dementia. J Am Geriatr Soc. 2017;65(7):1535-1542.
Morin L, Vetrano DL, Grande G, Fratiglioni L, Fastbom J, Johnell K. Use of Medications of Questionable Benefit During the Last Year of Life of Older Adults With Dementia. J Am Med Dir Assoc. 2017;18(6):551.e1-551.e7.
Lee SWH, Mak VSL, Tang YW. Pharmacist services in nursing homes: A systematic review and meta-analysis. Br J Clin Pharmacol. 2019 Dec;85(12):2668-2688.
Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Older medicare beneficiaries frequently continue medications with limited benefit following hospice admission. J Gen Intern Med 2019;34(10):2029-37.
Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691-700.