Cumulative Medicines
Current medications
- Diclofenac 50 mg twice a day as needed
- Apixaban 5 mg twice a day
- Aspirin 100 mg daily
- Rosuvastatin 10 mg daily
- Pantoprazole 40 mg daily
- Citalopram 20 mg daily
- Oxazepam 15 mg before bed as needed
- Atenolol 25 mg twice a day
- Amlodipine 5 mg daily
- Irbesartan 150 mg with hydrochlorothiazide 12.5 mg daily
- Glyceryl trinitrate (GTN) spray as needed for chest pain
- Fish oil 1000 mg daily
Albert is a 78-year-old male with multiple comorbidities.
Comorbidities include:
- Ischaemic heart disease (IHD) - coronary artery stenting some years ago
- Hypertension - last office BP was 118/75
- Atrial fibrillation (AF)
- Gastro-oesophageal reflux disease (GORD)
- Chronic low back and neck pain
- Overweight
Albert has been feeling dizzier and more nauseated recently and has noticed some ankle swelling.
His wife Josie states she has seen some bruising on his forearms. She feels he has worsening cognitive decline, is becoming more unsteady on his feet, and she is feeling less safe in the car when he drives.
You are Albert’s usual GP. He has a cardiologist and is awaiting geriatrician review.
Albert reports taking fish oil for joint pain as he believes it may be ‘good for that as well as his heart health and memory.’ He has not had any recent episodes of chest pain and has not used his GTN spray for years.
Albert’s Mini Mental State Examination (MMSE) score is 23/30. BP measures in clinic today suggest a postural drop; 123/79 sitting and 112/70 standing.
Implementing a patient centred stepwise approach to deprescribing
You have decided to refer Albert for a Home Medicines Review (HMR) but want to do a full assessment first by following a stepwise process to help guide your referral to the pharmacist.
1. Patient engagement and information gathering
You talk with Albert about how he is taking his medicines at home and how this matches what is documented in your records.
To identify potential harms, you type Albert’s medicines into the cumulative medicine risk tool.
You get the following result:
2. Document indications, benefits and potential harms
By using the cumulative risk tool you see that Albert is at risk of experiencing many potential harms including ones that may result in significant morbidity, with medicines contributing to falls risk, renal injury, bleeding risk and constipation.
You also consider the ongoing management of Albert’s chronic conditions:
- Prevention of complications of AF and IHD are important, but have the goals of care changed given Albert’s increasing frailty and cognitive decline?
- Assess depression – length of therapy and problems in the past. Current mental state.
- Hypertension – Albert is feeling dizzy – last BP was quite low, measures in clinic suggest a small postural drop. Reducing antihypertensive medicines may be appropriate.
3. Determine if medicine(s) can be ceased.
Prioritise. Agree and share a plan.
There are multiple medicines that could be considered for deprescribing, including:
Fish oil produces a theoretical increased bleeding risk for which there is little strong clinical evidence. There are contradictory findings about its benefit for heart health and memory. The risk is probably low but cessation is worth discussing, especially given Albert’s increasing unsteadiness and bruising.
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) which increases bleeding risk as well as renal and cardiac problems. Avoid regular or intermittent (PRN) use. There is potential to cease this therapy and consider non-pharmacological interventions for pain such as physiotherapy.
Amlodipine is a calcium channel blocker that may be contributing to ankle oedema. There is potential to consider ceasing with a plan to check BP soon. Rebound hypertension is unusual after ceasing antihypertensive medicine in elderly people1.
Rosuvastatin is an HMG-CoA reductase inhibitor (statin). Ongoing use of statin will depend on Albert’s situation and preferences.
Aspirin is an antiplatelet and apixaban is a directly acting oral anticoagulant. Bleeding risk significantly increases in patients over 75 years of age on this combination.1 A cardiology opinion may be warranted given this and the above mentioned concerns with Albert’s antihypertensives and statin.
Oxazepam is a benzodiazepine that is known to increases falls risk and confusion. You could plan to cease but you would need to taper slowly to prevent withdrawal effects if Albert has been taking this regularly.
Pantoprazole is a proton pump inhibitor (PPI). Long-term use of PPIs is rarely indicated and may increase risk of fractures and pneumonia. Reassess the management of Albert’s GORD in the context of his reported nausea and step down PPI therapy if it is no longer indicated.2
Citalopram is a selective serotonin reuptake inhibitor (SSRI). This medicine class is accepted as first line in the treatment of depression in older people but can cause hyponatremia and may increase fracture risk.3 Consider the ongoing need.
Ceasing or reducing medicines needs to be done slowly. In some cases, tapering is required to mitigate the risk of withdrawal effects or relapse. Prioritise medicines and make one change at a time to build confidence in the deprescribing process. This is especially important if Albert and Josie are feeling reluctant or unsure.
Use the table below to indicate whether you would consider ceasing each medicine, and the priority for cessation, noting that not all medicines should be ceased at the same time.
Having developed your prioritised list, re-enter the medicines in the cumulative medicines risk tool to see how Albert’s risk of harms has changed.
You consider ceasing one of the medicines that requires a tapering plan. Complete a tapering schedule for the relevant medicines for this patient by completing the boxes below
In planning your tapering schedule consider the length of time the Albert has been on the medicine, and the risk of withdrawal symptoms, including the likely severity of withdrawal symptoms.
Hint:
- for antidepressants visit Royal College of Psychiatrist’s guidelines
- for benzodiazepines, look at the tapering plan on page 11 of this deprescribing handout for patients
- for PPIs, look at the tapering plan on page 10 of this Deprescribing handout for patients
Consider and list the issues you will need to discuss with Albert and Josie to ensure they implement the tapering plan successfully.
For inspiration, have a look at the patient handouts developed by the Canadian Deprescribing Network
4. Monitor, support and document.
You offer to review Albert’s progress in one to two weeks to check any withdrawal symptoms and reassess BP.
You also write a referral for a medicines review to the credentialed pharmacist noting your concerns and ask them to explore if a dose administration aid could be beneficial. You include information about the plans you have for deprescribing in the referral, and ask the pharmacist to help you determine the priority for deprescribing.
Accredited CPD hours for GPs
To claim up to 2.5 hours of Reviewing Performance (0.5 hours per patient), please complete the following activity after reading the educational materials:
Find up to five of your own patients who may be at risk of medication related harm. Enter their current medicine list into the cumulative medicines risk tool. Consider the level of cumulative risk from their medicines and if there is opportunity for deprescribing.
If appropriate, refer these patients for a Medicines Review and ask the pharmacist to assist you in developing a deprescribing plan. Provide your patient with a copy of the brochure Talking to my GP and pharmacist about my medicines to explain the Medicines Review process and help them prepare for the review.
Note: to be eligible to claim 2.5 hours of Measuring Outcomes you must review a minimum of five patients.
Current medications
- Diclofenac 50 mg twice a day as needed
- Apixaban 5 mg twice a day
- Aspirin 100 mg daily
- Rosuvastatin 10 mg daily
- Pantoprazole 40 mg daily
- Citalopram 20 mg daily
- Oxazepam 15 mg before bed as needed
- Atenolol 25 mg twice a day
- Amlodipine 5 mg daily
- Irbesartan 150 mg with hydrochlorothiazide 12.5 mg daily
- Glyceryl trinitrate (GTN) spray as needed for chest pain
- Fish oil 1000 mg daily