Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk episode 184 I'm your co host, Dr. Kane, Dr. Khyati Patel 00:35 and I'm Dr. Patel, and the title of today's episode is, drop it like it's hot, deprescribing pharmacotherapy when appropriate. So Dr Dr. Sean Kane 00:44 Patel, clearly we're talking about getting rid of medications. And this is actually not a new topic for us in terms of HelixTalk, covering the concept of deprescribing and kind of how to Dr. Khyati Patel 00:53 do it. Yeah. So back in episode 57 we kind of talked about use and overuse of PPIs. And then we did another episode about de prescribing PPIs, which was episode 129, and then back with Dr. Michael Schuman, we also discussed, you know, benzodiazepine taper. So it's not really deprescribing, but like tapering off unnecessary benzodiazepine. This was an episode 68 today's episode. We're not focusing on these discussions because they already happened in the past, but we're going to focus on drugs such as the benzodiazepine receptor agonists, cholinesterase inhibitors, memantine, antipsychotics, and antihyperglycemics. For these drugs, there are set guidelines or guidance out there, and that's the reason why we are focusing on these Dr. Sean Kane 01:39 and de prescribing might be a new term for people. I think most people kind of intuitively understand it's where you get rid of a medication, but it's a little bit more than just getting rid of it. It's like the planned process of, how do you taper off if you need to taper down the dose, and then how do you supervise the patient? So that monitoring component, what are you actually looking for, is really important so that you're trying to maximize the benefits of getting rid of the medication and minimize the downsides of not having whatever that medication was being used for, and preventing some of the, let's say, withdrawal phenomenon that can happen when you discontinue a medication Dr. Khyati Patel 02:13 right and they also lay down that this is a shared decision making that needs to happen between patient and provider or patient care team caregivers, it's important that patient understand the rationale for why it's necessary. So we need to have their buy in that they're ready to do so for a successful outcome, so they don't end up back on the medication, and, you know, probably back where we started. Dr. Sean Kane 02:35 What's interesting is that the concept of deprescribing is one of those things that, like, everyone agrees is a good thing to do, like, of course, you should have fewer meds that you don't need, with less cost and less side effects. But the problem is that in practice, it's actually somewhat difficult to actually de prescribe and go through the thought process and the actual execution of de prescribing medications. Why is that so difficult to actually execute in practice? Dr. Khyati Patel 02:59 Yeah, I think there are barriers to the deprescribing. Is, you know, a lot of the conditions we are treating are chronic conditions, and so usually the treatment algorithm for any chronic condition is that it worsens with the age, and so we need more medications to control it, right? So in our heads, it's always about adding medication and maximizing therapy, rather than really looking at, okay, this medication has no longer a place in therapy, or it's acting more on a harmful way than beneficial way. We need to remove it. And the other thing is too, which I notice a lot when it comes to polypharmacy, patient goes to like multiple different providers, and Dr. a doesn't talk to Dr. C, and both of them don't complete, come to an agreement on starting a medication, or Dr. A is a PCP, but then Dr. d started a medication, and they're like, Dr. d started it, I'm not touching it right, even though, if it's unapprop inappropriate. So there's this notion that once the drug is on, it's always an on drug, unless, obviously it's an anti infective. Dr. Sean Kane 04:00 And I'd say, even in the ICU setting, this is actually a really common phenomenon, and some of my favorite providers that I used to work with would be comfortable, kind of being the head honcho, the person that said, like, I am in control of all aspects of this patient's care, and if I don't think they need a medication, I'm either going to reach out to the provider right now and figure it out, or I'm just going to get rid of it, because I'm in charge, right? And I think ideally, that's the role of the primary care provider or the intensivist in the ICU or the hospitalist in the hospital. But sometimes you have so much going on, it's hard to play that role, and you don't want to mess up. You don't want to get rid of a med that someone really, really wanted, or make a change that a consultant added two years ago, that maybe there's a good reason, and you don't know what that reason is. Is this more work to do that, right? Dr. Khyati Patel 04:44 Yeah, kind of have to dig into the, you know, the history behind why that medication was started, and some clinicians are not comfortable doing so in the given moment of time. Usually we practice this principles for, you know, polypharmacy and deprescribing for our older patients. Populations, that's where we look at risk versus benefit, but honestly, younger patients too, who've been on these medications unnecessarily. We can use similar principles of deprescribing, and then you can review literature around the principles of deprescribing and what steps that needs to go into the consideration. But there's usually four or five steps that we consider. Dr. Sean Kane 05:22 So the first step is, why are you taking the medication? Right? So the number of patients that I've encountered where they're on omeprazole or famotidine, they don't have GERD, they've never had GERD, but it got started at a hospital visit two years ago, and everyone just continues it. That would be a great reason to think about, well, why are you taking it? And if there's no indication, there's no benefit for the patient, right? Right? Dr. Khyati Patel 05:45 And we discussed some of the beers list as we're at start and stop criteria in a previous episode. And that's another way we can pitch the appropriateness or indication for medication. The other one is risk and benefit evaluation. Right? At one point when the medication was started, it was beneficial and the risk was low. But as we age, our body dynamics changes. Maybe the side effect of the medications can mount too. When we are introducing polypharmacy, there is more drug interactions and stuff, so the harm of the medication increases. So you got to have to evaluate that risk versus benefit, and how intense the risk is, will decide what your de prescribing strategy is. That means, do you want to just completely stop the medication? You want to do a fast taper versus you want to do a slow taper? So you kind of have to evaluate all of that at once. Dr. Sean Kane 06:34 And really, like when you think about risks and benefits oftentimes, but not always, your benefits are sometime in the future, right? So, like, you take a statin to not have a heart attack or a stroke in the next 10 years and reduce it by 25% but oftentimes the side effects happen right now. So then you also have to weigh those future benefits versus the current risks that the patient is having, and that, again, is a great opportunity for shared decision making with the patient, because they're the one that is experiencing the side effect or the cost or whatever Dr. Khyati Patel 07:04 it is. Yeah, absolutely. And then in the laundry list of things, you may identify five medications that need an action or change. But then you got to have to prioritize, right? So which one needs to come up first? So again, that goes back to again, the harm intensity and which one we should go after, first the fight the battle today, and then which one we should consider fighting it later on. So prioritizing which drug to discontinue first also is part of the steps there. Dr. Sean Kane 07:32 Really. The last step is the kind of follow up and monitoring aspect that you have a plan. You know exactly how you're going to taper the regimen, but during that process, especially for meds that have a withdrawal symptom associated with them, you need a monitor for that. So if they start having that symptom, maybe you back off and have a less aggressive taper. Or maybe there's some benefit that the med was giving them that now they don't have that benefit, some new symptom that that med was treating, maybe you need to go back. So the follow up monitoring for both safety and efficacy is really important with your deprescribing approach, Dr. Khyati Patel 08:05 yeah, and the implementation part is also important. Dr. Kane mentioned that I'm approached at the clinic for deprescribing some of these drugs, and I follow these guidelines. And some of these tapers tend to be 1618, weeks long, and so you have to create a nice schedule for the patient. And sometimes the commercially available doses don't really fit into this, like decreased taper schedule for you. So you may you might be ready to change the strength of a medication, and patient needs to know this, and you know, provider needs to know this, exactly what to prescribe and how to de prescribe. And so implementation piece, working with the teams is also important, I Dr. Sean Kane 08:42 think, really at the end of the day, thinking about what is our goal for deprescribing is really important. Our goal is to have less medication burden that ideally would be benefit to the patient, in terms of less cost, less pills that they have to take per day, but the net effect is an increase, or at least maintenance, of their quality of life, right, which is captured by cost, side effects, things like that. But that is our main goal. So always approaching de prescribing from that lens, I think, is really important, yeah. Dr. Khyati Patel 09:11 And you may wonder, Dr. Kane, you know, we are talking about these different steps and principles, and that's that's not new, you know, that's kind of pharmacotherapy evaluation, medication review and change process. But where are, you know, some of the guidance and evidence based literature coming from. So we have some guidelines, as well as practice networks that are forming that are advocating deprescribing. And so the very old, the first one was established in 2014 by Australian Government, Australian de prescribing network. We also have Canadian medication appropriateness and deprescribing network that was formed in 2015, and then 2019, year old and three new popped up, English deprescribing network, the Northern European Researchers in Deprescribing, they like to call themselves nerds, and then us Deprescribing research networks. You may wonder what these deprescribing networks are really, this is group of individuals, includes clinicians, researchers, policy makers, patients themselves, patients advocates. They come together and advocate for de prescribing. And not just, you know, this Losey goosey say yes, get rid of that medication. But really, researchers are looking from the evidence perspective, looking at the literature, looking at the trials that have done the prescribing, and providing the evidence based mechanism for clinicians and patients to work together to do that. Dr. Sean Kane 10:36 There's even guidelines out there so deprescribing guidelines like deprescribing.org. This is pharmacist researchers and academicians who develop evidence based guidelines and tools to help providers know how to do the deprescribing thing. It's also available as a free app, which is always nice, and really, these guidelines are going to tell you what things you should consider deprescribing, and then, if you choose to deprescribe. How to actually go about doing that? Dr. Khyati Patel 11:03 Yeah, so exactly you know when it is appropriate to de prescribe, and if you do go down that route, then how are you going to deprescribe? There's tons of other available healthcare provider tools on this website too, including patient handouts, you know, webinars, workshops and learning modules. They include the prescribing current guidelines for PPIs, antihyperglycemics, antipsychotics, and the benzodiazepine receptor agonists. Couple new guidelines are in the making diuretics as well as statins. And then the other organization is the Australian de prescribing network. And these are group of individuals who have developed the cholinesterase inhibitors and memantine deprescribing as well as opioid deprescribing guidance. Dr. Sean Kane 11:47 So Dr. Patel, maybe we can take a couple of minutes to go through some of these guidelines and kind of summarize what are some things to think about when you're de prescribing some of these drugs or drug classes, and then just the general approach. And maybe we start with the antipsychotics, which is one of those deprescribing guidelines from deprescribing.org Dr. Khyati Patel 12:06 so antipsychotics, I mean, you got to think first thing, what is the indication patient? Or why are you using antipsychotic for a given patient? There are laundry list of, you know, indications where antipsychotics are actually appropriate. Some examples are Tourette's Syndrome or schizophrenia or bipolar disease or OCD, autism, etc. However, there are certain conditions where the antipsychotic long term use is considered inappropriate, and those will be in patients who have behavioral and psychological symptoms of dementia, such as, you know, agitation, aggression or psychosis for more than three months. And so that's, that's one big red flag, if you see it, and antipsychotics are on board that it's time to de prescribe. Dr. Sean Kane 12:52 The classic example of this would be a nursing home patient who gets agitated, or they're just very impulsive and they're very difficult to kind of control, and they use the clinicians are using this to for patient safety, to keep the patient safe, but ironically, all antipsychotics have a boxed warning that if you use it in elderly patients with dementia related psychosis, that it increases mortality. So that's one of the big reasons that you would like to de prescribe these, assuming it's somewhat safe to do for the patient, or find other ways to control their agitation, because it is associated with an increased risk of mortality, which is a really big deal. Dr. Khyati Patel 13:30 Some clinicians might be using it for primary treatment of insomnia or maybe secondary treatment of insomnia when there is underlying some of these, you know, psychological conditions that are managed and so those are the instances where de prescribing would be recommended per these guidelines. Dr. Sean Kane 13:46 So in those cases where you're using it for primary or secondary insomnia, this is easy. You literally just stop the medication. Usually, these patients are already at a fairly low dose compared to, let's say, schizophrenia, so usually there isn't much room to taper anyway, and just stopping it is the best approach, right? Dr. Khyati Patel 14:04 However, if they were using it for that behavioral, psychological symptoms of dementia, then they probably are using it at higher dose, and the recommendation is to taper the dose and then stop the therapy altogether. So how do you taper? It is a big question. All ties down to the drugs, pharmacology and pharmacokinetics, as to how it clears from the body. The approach here is 25 to 50% reduction in dose every one to two week. So got to create a nice table, as I mentioned earlier, that helps the patient to kind of stick to every week what dose they need to take, and kind of help them visualize it. And you might have to change the formulation, you know, maybe 400 milligram doesn't cut into 100 milligram. And so you might have to go ahead and prescribe 200 milligram where they can then cut it into 100 milligram, Dr. Sean Kane 14:54 for example. And then we mentioned one of the important aspects of this is the follow up and monitoring. So do. During that period where you're cutting down the dose every one to two weeks, you should be looking for any symptoms of withdrawal, which could be things like they're a relapse of the thing that you were trying to treat. So if they have that behavioral related psychosis, so worsening psychosis, aggression, agitation, delusions, hallucinations, any of those things would be an indicator that they might be withdrawing, and you might have to slow your taper down, maybe even go back a step to where they previously were. Yeah. Dr. Khyati Patel 15:29 And then you're looking for looking out for benefits, right? So are they a little bit more alert since we have stopped the antipsychotics? Have you noticed any changes in their falls frequency? Have you seen improvement in gait and then reduction in those extrapyramidal symptoms, and Dr. Sean Kane 15:46 then the guidelines also mentioned that, you know, if this was originally for insomnia, they do talk about alternatives, or even for the behavioral related psychosis, they talk about alternative options that aren't that anti psychotic, that you're getting rid of that could help address some of those symptoms that the patient may have with a relapse type picture, right? Dr. Khyati Patel 16:06 So in a nutshell, you know, they're not just saying taper it off, and then patients on their own, they're saying like these are some additional things that clinicians may consider to help patients if they are relapsing. Dr. Sean Kane 16:17 So then our next category, Dr. Patel, is benzodiazepine receptor agonists. And this was kind of a newer term for me. I wasn't familiar with this. Could you talk about what the term means and why we have this term versus just benzodiazepines, right? Dr. Khyati Patel 16:32 So technically, if you look at the guidelines and the header, it does say benzodiazepines and Z drugs, deprescribing, and so we already talked about benzodiazepine de prescribing in the past. However, these principles that we are focusing on for the Z drug, so we're talking about zolpidem, type of drugs, they're just kind of lumped up together, so the principles kind of are applying to both of them. Dr. Sean Kane 16:56 So with these benzodiazepine receptor agonists, if you're taking this for restless leg syndrome or unmanaged anxiety, depression or other mental illness that either causes or aggravates insomnia, you probably want to continue these for right now. Now, just as a general rule of thumb, you don't want to be on benzos long term, but some patients need them, and despite maximizing their SSRI therapy and other therapies, this is what they need, but ideally you want to use the minimum dose for the shortest duration possible. But that may not always be possible for a patient. Dr. Khyati Patel 17:29 And so when does the de prescribing is recommended for the Z drugs, right? This is pure insomnia, or insomnia that is managed with underlying comorbidities. And then the guidelines kind of break it down their strength of recommendation based on the age. So again, this is evidence based. So if your patient has insomnia and they're 65 years and older, they're taking these, you know, benzodiazepine receptor agonists, for any duration, there's a strong recommendation for considering de prescribing for age 18 to 64 years old, if they're taking it for more than four weeks, we should consider or recommend the prescribing. And this is a coming from little bit of a weaker recommendation. Obviously, 65 and older is a stronger recommendation, because we know the harm from those drugs in older patients. Dr. Sean Kane 18:18 So then if you choose to try to de prescribe. The approach here is to taper and then stop, so a 25% reduction in dose every two weeks, and then a 12.5% reduction near the end, including planned drug free days. So that would mean that if they normally take it every single day, as you get to those very low doses, you might try to take it every other day and kind of see how the patient does with Dr. Khyati Patel 18:41 that, right? And when I first helped the clinician and followed this algorithm, I had a hard time accepting that there are days where they won't be taking the medication. And you have to realize that that doesn't happen until the very like, last few weeks that they're, you know, in the taper process. But it's okay, yeah, they might be taking it just, you know, quarter of a tablet or half a tablet on three days a week, and then we stop thereafter. Dr. Sean Kane 19:06 You have to remember, like some patients take these Z drugs like that anyway, right? They might take three or four doses in a given month just because they need it on certain days, or whatever is going on. So it's not like you're violating how it's normally dose, but usually these patients are taking it daily, and they've been on it for a while. That's why you can't just skip to that, you know, almost PRN type dosing, right? Dr. Khyati Patel 19:29 That makes sense. And again, we are going to monitor these patients every one to two weeks for withdrawal symptoms, right? So are they experiencing insomnia now they're taking the medication away from them, and any anxiety, irritability, sweating, some GI symptoms. However, know that these withdrawal symptoms from the Z drug tends to be mild and last for only few weeks. And this is where patient buying comes in, getting them ready and say, you may experience this, but they tend to be mild and they should go away. Dr. Sean Kane 19:58 And really the offset of that is that. Because they're on a lower dose, or even not taking it as frequently, they should be more alert. They should have better cognition, maybe especially in the morning. They have less daytime sleepiness because they don't have the residual effects of the medication. And then, especially for older patients, we're hoping to reduce the risk of falls, which is associated with these Z drugs. Dr. Khyati Patel 20:20 And then, as we all know it, right treatment of insomnia has to be pharmacological as well as non Pharm. So these guidelines kind of talk about our non Pharm approaches such as cognitive behavioral therapy or their behavioral modifications that could be done in order to improve this condition. Dr. Sean Kane 20:40 So then our next group of drugs are the cholinesterase inhibitors and Memantine de prescribing. So this is merged into one guideline because it's pretty common that patients are taking both of these drugs at the same time. This is primarily going to be for Alzheimer's disease, but you'll see it for other diseases as well, right? Dr. Khyati Patel 20:57 So if the patient is taking it for Alzheimer's disease or dementia of Parkinson's disease, Lewy body dementia, or vascular dementia. And the vascular dementia is really just the indication for the cholinesterase inhibitors, not for memantine. They do not and do not meet any of the conditions we're going to talk about in just a little bit. Then they could continue taking it. However, if they have Alzheimer's disease, dementia of Parkinson's disease, Lewy body dementia, or vascular dementia. And then we can break it down into, you know, long term versus short term. So the term limit here is 12 months. So anything more than 12 months, it's considered a long term. Anything less than 12 months is short term. And then the guidelines breaks it down in addition to this time period in the use, if there are certain conditions that is true. So for example, if the patient has been using it for more than 12 months. And if any of this is true, such as, we are noticing worsening of cognition over the last six months of use, or even less than that, we have noticed that patient has not had any benefit from using the therapy or patient is at the severe end stage of dementia. They are saying we need to consider, you know, deprescribing. Dr. Sean Kane 22:09 And you know, intuitively, this makes sense. If you think of any other medication out there, of someone's been on a medication for a long time and it's not working, you should get rid of it. The problem with these diseases, the variety of different kinds of dementia, is that there isn't much else to offer these patients. And a lot of times that's the reason to not be prescribed, is there's not much to have as an alternative. And I get that, but if it's not working, having no other alternative is better because you're replacing it with nothing which has no side effects and no cost associated with it, and things like that. So I think that that may be some of the hesitation to get rid of these medications, but we have to realize that there are harms associated with taking a medication that doesn't have any benefit, right? Dr. Khyati Patel 22:53 And I think when we're looking at the short term use, that's when we are thinking more, you know, involving patients and shared decision making. So maybe it's a family decision that we want to decrease the pill burden, right? We don't need to use this medication. Maybe patient gets to the point in their disease process where they're unable to take the medication. Maybe there is not enough support. Maybe because of that reason, there is this non adherence. You try to solve it, but they're just not able to take the medication like it's prescribed. And then with polypharmacy, right? These drugs are interacting with other medications and stuff. So again, they're not useful, but then they're causing or contributing to drug interaction to some useful medications. Then you got to remove the not useful medication. And again, patient has any other terminal illnesses that are not associated with dementia, right? So maybe they have cancer, right? And it's palliative care at this point. And then if they have severe agitation or psychomotor restlessness, these are all the reasons we would be recommending deprescribing for. Dr. Sean Kane 23:58 So clearly, there's a lot of like decision points that come into this again, with both of these drug classes, they're not amazingly effective in treating dementia. So there is going to be a lot of patients that are going to meet many of these criteria to get rid of it. But again, the problem is that there aren't that many alternative things that you can offer to be a treatment for this disease state, which is really sad. Dr. Khyati Patel 24:19 Yeah, and the deprescribing process for this one would also be taper and stop it's a little bit interesting of a taper, like 50% or half the dose in every four weeks to the lowest available dose, and then you can go ahead and stop it. So your schedule is going to look a little bit different here. And the follow up, though, you're going to do also a little bit slower than the other ones. Every four weeks, we're going to check for cognitions, patients, functional status, as well as neuropsych symptoms. Dr. Sean Kane 24:50 So then our next category of deprescribing are opioids. And this is a whole topic in itself. There's a lot to this one, but you'll find opioid deprescribing. Guidelines by Australia's deprescribing network, in general, the CDC opioids, opioid prescribing, which also addresses the prescribing should be considered as well. So there's kind of different guidelines out there Dr. Khyati Patel 25:13 to think about. Yeah, the CDC is opioid prescribing. Guidelines were updated in 2022 and there, to some extent, do talk about, you know when to go ahead and describe or taper opioid therapy, but it's it's not by any means, a greater extent focus. However, we know opioids are good for certain conditions, but not good for many other conditions. So obviously, if patient is taking it for palliative care, palliative pain or chronic non cancer pain or chronic cancer pain and patient has severe opioid use disorder, they're saying, Go ahead and let the patient continue. However, if they do have that severe opioid use disorder along with it, then what we want to do is offer the medication assisted therapy for them to be off of opioids in Dr. Sean Kane 26:01 terms of who would be appropriate for deprescribing. These are patients with chronic non cancer pain or chronic cancer pain. They do not have severe opioid use disorder, and they meet certain criteria. So some of those criteria would be that they lack functional pain or quality of life improvements despite taking an opioid, they're having really bad side effects to their opioid like constipation or cognitive impairment or dizziness or nausea, things like that. They have comorbidities that are worsened by the opioid. So COPD and sleep apnea, in terms of decreasing the respiratory drive, would be an example of that. Dr. Khyati Patel 26:34 Then some other ones would be, you know, they're using other medications that would increase sedation, right? So Gabapentin alcohol, although we know they should tell them not to use that together or other sedating antidepressant therapies, right? Antipsychotics also, and whenever opioid doses are very high, we know high opioid doses can lead to respiratory depression, especially when they're using along with certain other drugs like muscle relaxants or even benzodiazepine the risk of respiratory depression is really high, so maybe take it down a notch and give them optimal doses. However, we know pains principle, it's kind of tachyphylaxis, right? So over the time, patients need more and more doses of opioids to get the same amount of pain relief. So this one's a little bit harder to do. In addition, patients who are using opioids for acute pain for longer than one week of duration, or they're using it on a schedule basis, the deprescribing is also recommended technically. For acute pain, you know, you get a prescription for opioids. Doctor tells you, you know, take it for three or five days or take it as needed, that's probably okay. However, if they're taking it for more than a week on a consistent basis, the risk of, you know, being dependent on it also increases. Dr. Sean Kane 27:51 So in terms of our strategy for those acute pain patients, where they've taken it regularly for less than a week, you just stop. There's no reason for tapering, because they don't have a physical dependence on the opioid with even a week of consistent use, but things change a little bit when it's more of a chronic patient. So one approach is an individualized, gradual taper, and this is for patients where the risk of harm in terms of withdrawal is higher or worse than just abruptly stopping. So if they've been on it for less than three months, every week, you're going to decrease the dose by about 10 to 25% if they've been on it for more than three months. So truly, that very chronic patient, you're going to decrease it by 10 to 25% same amount, but every four weeks instead of every week. So your tapering frequency is going to be less frequent if they've been on it for more than three months, if they've been on a really long term, more than a year. The key here is slowly tapering and frequently monitoring. Dr. Khyati Patel 28:46 Yeah, they don't give a particular percentage for that, but the answer is, you're going to be, you know, working with the patient over a few weeks, if not. I do want to mention that even though CDC guidelines for opioid prescribing mentions importance of de prescribing, they don't get to the specifics like these guidelines do in terms of, you know how much taper every week you want to or every four weeks you want to consider based on the amount of opioid use. So I really like it, because it gives you a clear idea of how to go about it. Dr. Sean Kane 29:18 So then, as that patient is tapering and you're looking for opioid withdrawal, those symptoms would be nausea, vomiting, diarrhea, abdominal cramping, and then just pain, especially muscle and joint pain. Dr. Khyati Patel 29:30 And then you'll be also looking out for any cognitive or functional status, including How's their sleep, their mood, their pain control, and also, obviously, behavioral, and psychosocial symptoms. I think with opioid deprescribing, one thing is really important, especially when they have that physical dependence, is educating the patient and using harm reduction strategies, right? So if they do return to use the same amount of opioid dose once they are tapered off of. It their risk of overdose is exponentially high, and for this reason, if appropriate, patients should be given harm reduction strategies such as Naloxone, so they should be taught how to use it properly. Dr. Sean Kane 30:14 So then our final category of de prescribing are anti hyperglycemics. So these are medications used for diabetes, in terms of what our approach is, and things like that. It kind of depends on a variety of factors, Dr. Khyati Patel 30:27 yeah, and I think some of this, we also discussed Dr. Kane when we talked about viewers criteria, or startup stop criteria. And I felt like, you know, just teaching diabetes and stuff, when I looked at it, this is a specific population management as we do for diabetes in patients who are 65 years and older. I think they're trying to make this into a guidelines to normalize the fact that older patients can afford a little bit of a less, stricter control of their agency. And so the guidelines are kind of saying, you know, you could consider deprescribing a patient is 65 years and older, obviously, type two diabetes, and if they are at a higher risk for hypoglycemia. So maybe we have too many medications and we are strictly controlling their glucose. Maybe there is drug interaction, multiple comorbidities. Maybe we know that they don't feel the symptoms of hypoglycemia. So there is a hypoglycemia unawareness. Maybe they're on a high hypoglycemia risk medication, such as the sulfonylureas and the insulins, or impaired renal function, which kind of slows down the clearance of this medication, increasing the risk of hypoglycemia. Dr. Sean Kane 31:36 Then, of course, certain anti hyperglycemic medications have side effects. So if they're experiencing some of those side effects, and we want to address that, that might be a really good reason to get rid of one of these medications. Dr. Khyati Patel 31:47 And another thing to look at is, how old is your patient? What is the expected benefits of continued therapy, such as, if the patient is in palliative care? Are we really trying to extend their life right? Frailty and dementia, these type of health conditions should also be looked at in in kind of individualizing that even C goal, and you look at the ADA guidelines or A's guidelines, they're all saying like these factors should be looked at, and if appropriate, those patients should be kept at less than 8% even see gold or less than 8.5 this is, again, is going to be that shared decision making process. Dr. Sean Kane 32:23 I just want to be clear, we're not saying that we should be deprescribing on the 45 or 55 year old individual with type two diabetes. This is for older individuals where really, some of the risks associated with diabetes management might be outweighing any of the benefit they may be deriving. So this is different than many of our other categories that we've talked about, where long term use of certain meds is generally not recommended, but sometimes done. This is different, where it's pretty normal to be on anti hyperglycemic medications for decades, and that isn't necessarily a reason to get rid of them because they've been on it for too Dr. Khyati Patel 32:59 long, right, right? And I think that's the reason the de prescribing is very individualized based on the agent they are on how long they've been on it. For example, if it's sulfonylureas and insulins, you could either reduce the dose and then stop or just stop abruptly. For example, with the insulins, we have certain insulins that are higher hypoglycemia risk versus some of the other new, cleaner ones, such as, we should try and change the medication to less hypoglycemia causing one right? So the good example is, if they're on NPH, try to change them to glargine, or even degludec, because those are associated with less hypoglycemia. Dr. Sean Kane 33:39 For other drugs, especially our oral therapies, reducing the dose, especially if they have renal impairment, and they probably should have been on a lower dose anyway, be thinking about that, and then also switching stopping or reducing the dose. And then stopping is also another option. So if they're on sulfonylurea A, and you want to switch them to sulfonylurea B, because it isn't as renally eliminated, that gives you a more consistent kinetic profile that would be reasonable reducing the dose and then stopping would also be an approach that could be done here. Dr. Khyati Patel 34:09 Yeah, and you know, some of these patients might be put on monitoring for the blood sugar. So you're going to monitor those blood sugars daily for one to two weeks to make sure there is nothing, you know, crazy going on with that for diazolin and ions like the pioglitazone, because they take so long to start working, but they also take so long to stop working. We're going to monitor this for about 12 weeks, and you're looking out for symptoms of hyperglycemia or even hypoglycemia, right? If you're changing the therapies and considering kind of increased doses or restarting the medication if hyperglycemia returns. You know this is again going to be very fluid at this point, but the idea here is that you're doing something about it, rather than just being status quo. Dr. Sean Kane 34:54 And ideally a patient is checking their sugar because you told them to do that. But if they're not. Dr. Talbot. Are some symptoms that a patient may have for both hyper and hypoglycemia that they could also self monitor for, Dr. Khyati Patel 35:05 yeah, classic symptoms for hyperglycemia will be those three P's, right? So, polyuria, polydipsia, polyphagia, blurred vision, headaches and dry skin, dry mouth, all of that. For hypoglycemia, lot of reactions are based on adrenergic system, so palpitations, sweating, jitteriness, confusion, feeling hangry. I like to call it. Those are some of the telltale signs. Also, I've had patients over the years who say my leg starts to hurt and I know my sugar is low, so you got to kind of go with that, even though that's not a normal symptoms of hypoglycemia. Dr. Sean Kane 35:43 Well, Dr. Patel, I think we've really reviewed a lot of different categories and the principles of de prescribing and some specific examples at the end of the day. Some key concepts are one that medication appropriateness and the concept of de prescribing is largely based on risk and benefit, but a lot of this is focused on elderly individuals, because they tend to have a more clear cut risk versus benefit profile than someone who's a little Dr. Khyati Patel 36:08 bit younger, right? And there is this emerging trend of de prescribing networks that conduct research and provide evidence based recommendation on how to de prescribe certain medications used for those specific conditions. And so those are really useful for clinical practice. Dr. Sean Kane 36:25 And Dr. Patel, as you mentioned earlier, you're very commonly consulted or curbsided for how do i de prescribe XYZ? For the listeners, there are guidelines out there that make this more evidence based approach, versus you kind of coming up with what sounds reasonable, right? So we do have guidelines for PPIs, benzodiazepines, benzodiazepine receptor agonists, opioids, antipsychotics, cholinesterase inhibitors, Memantine and antihyperglycemics. So you might as well at least peek at those guidelines and then make an individual decision for that particular patient in terms of the best approach for that individual. Dr. Khyati Patel 36:59 And this is sort of generally speaking, but a general approach for de prescribing is gradual tapering of the drug over several weeks and then discontinuation, all the while having a proper plan for monitoring patients for any withdrawal symptoms or looking out for those benefits of discontinuation. Some drugs do need abrupt discontinuation, but most do follow this taper and stop principle. Dr. Sean Kane 37:26 And if you'd like to take a look at those guidelines, we have references in our show notes for deprescribing.org and also the Australian prescribing network. Again, there are other guidelines out there, but those are the two that we used in this particular episode, and you can access those on our website at HelixTalk.com Again, this is episode 184 we also have a mailing list. If you would like to get an email whenever new episodes are dropped, you can get that in your inbox, and you can also sign up at HelixTalk.com so with that, I'm Dr. Kane, Dr. Khyati Patel 37:54 and I'm Dr. Patel, and I just like to give a big shout out to our friends up north for putting together this deprescribing.org and guidance, which is very clear cut, rather than clinicians having to pull up one article at a time. So thank you to those pharmacist researchers up in Canada who are doing excellent work, and hope there is more research networks out there, and we will have good guidance and recommendations available for clinicians in the future. So with that study hard, yes, thank you. Narrator - Dr. Abel 38:25 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 38:36 to suggest an episode or contact us. We're online at HelixTalk.com. Thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.