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Ontario Deprescribing Project Update - July 2014
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Ontario Deprescribing Project Update
July 2014

The evidence based Deprescribing guidelines aim to support interdisciplinary teams of healthcare professionals in tapering or stopping medications and monitoring for adverse drug withdrawal reactions in elderly patients. The project’s research team expects that this will reduce adverse drug effects, polypharmacy, and improve quality of life.

News

Proton Pump Inhibitor Deprescribing Guideline (Guideline #1)

Proton Pump Inhibitor (PPI): A class of medications/drugs that reduce acid production in your stomach. They are commonly used to treat heartburn, among other conditions.
  • First deprescribing guideline team has finished its draft guideline; clinical review is complete.
  • Implementation of the PPI Deprescribing Guideline has started at 6 sites in the Ottawa area. Some of our sites include:
    • Long-Term Care Facilities
      • Hillel Lodge
      • Perley and Rideau Veteran’s Health Centre
      • St. Patrick's Home of Ottawa
    • Family Health Teams
      • Bruyère Academic Family Health Team
      • Rideau Family Health Team

Benzodiazepine Deprescribing Guideline (Guideline #2)

Benzodiazepine: A class of medications/drugs also called “hypnotics” or “sedatives” that are commonly used for insomnia, among other conditions.
  • Welcome to Benzodiazepine Deprescribing Guideline Development team members:
    • Dr. Kevin Pottie, MD, Clinical Scientist, C.T. Lamont Centre, Bruyère Research Institute (Guideline Lead)
    • Dr. Cynthia Boyd, MD, Associate Professor, Center on Aging and Health, School of Public Health, Johns Hopkins University
    • Dr. Simon Davies, MBBS, Assistant Professor, Department of Psychiatry, University of Toronto 
    • Dr. Barbara Farrell, PharmD, Clinical Scientist, C.T. Lamont Centre, Bruyère Research Institute
    • Dr. Anne Holbrook, MD, Professor, Division of Clinical Pharmacology and Therapeutics, Department of Medicine, McMaster University 
    • Dr. Cheryl Sadowski, PharmD, Associate Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta 
    • Dr. Robert Swenson, MD, Professor, Department of Psychiatry, Faculty of Medicine, University of Ottawa
    • Dr. Vivian Welch, PhD, Clinical Epidemiology Methodologist, Bruyère Research Institute
  • The team met on June 26, 2014 to establish the scope and parameters for development of the Benzodiazepine Deprescribing Guideline.
  • We anticipate the guideline will be ready for clinical review this Fall.

Spreading the Word

  • The Center of Research Excellence at The University of Queensland Australia hosted its first National Workshop on Deprescribing on May 20, 2014. Our project’s Principal Investigor, Barbara Farrell, presented to an international audience via Skype on the topic of making deprescribing part of routine care. Participants showed great interest and expressed their appreciation on social media.
  • PPI Deprescribing Guideline Development team members Kate Walsh and Barbara Farrell facilitated a 45 minute workshop for over 100 Canadian Pharmacists Association members at their annual meeting in Saskatoon, SK. on June 2, 2014. Participants provided excellent feedback about the guideline and associated tools which were incorporated prior to pilot site implementation in later June.
  • About 20 people attended a session on the Deprescribing project at the 2014 Canadian Evaluation Conference in Ottawa on June 17. James Conklin, co-Principal Investigator on the project, explained how developmental evaluation is being used to gather and analyze qualitative data about the deprescribing team’s process, and to help the team strengthen its capacity to develop and implement deprescribing guidelines. The session was followed by a lively discussion, suggesting that the deprescribing project is of interest to both clinicians and evaluators.
  • The Deprescribing Team plans to disseminate the unique methods of the Deprescribing project to North American audiences this fall with abstract submissions to: 
    • AGM of the Regional Geriatric Program of Eastern Ontario, October 2014 (Ottawa, ON)
    • Annual Meeting of the North American Primary Care Research Group, November 2014 (New York, NY)
  • On Twitter, @Deprescribing is excited to have over 600 followers!
    • Have you deprescribed a medication, managed a patient with polypharmacy, used an effective nonpharmacological intervention? Have you had a personal experience with reducing or stopping medication? Tweet us your deprescribing stories.
    • What do you want to know more about? Tweet us with your questions or comments!

Spotlight on Deprescribing

Clinical Tips for Deprescribing

  • As people age, cardiovascular medications, including antihypertensive therapies, should be regularly reviewed when assessing common geriatric presentations such as falls, dizziness and hypotension. (1)
  • The differential diagnosis of any sign or symptom should always include the question, “Could this be caused by a drug? (1)
  • Drugs with anticholinergic properties can have additive effects, with the result being a high anticholinergic load. (2)
  • Use the Beers or STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) screening criteria to identify “potentially inappropriate” medications for the elderly. (3)

Useful links

  • Articles on anticholinergic load
    • Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry 2001;62(Suppl 21):11-4.
    • Ancelin ML, Artero S, Portet F, et al. Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: longitudinal cohort study. BMJ 2006;332:455-9.
    • Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008;168:508-13.
    • Mintzer J, Burns A. Anticholinergic side-effects of drugs in elderly people. J R Soc Med 2000;93:457-62.
    • Carrière I, Fourrier-Reglat A, Dartigues JF, et al. Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study. Arch Intern Med 2009; 169:1317-24.
    • Pasina L, Djade CD, Lucca U, et al. Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: results from the REPOSI Study. Drugs Aging 2013;30:103-12.
    • Shi X, Wray DW, Formes KJ, et al. Orthostatic hypotension in aging humans. Am J Physiol Heart Circ Physiol 2000;279: H1548-54.
  • BEERS Criteria: www.americangeriatrics.org 
  • STOPP Criteria: biomedcentral.com 

Sources 

  1. Reducing fall risk while managing pain and insomnia: Addressing polypharmacy in an 81-year-old woman. Canadian Pharmacists Journal : CPJ = Revue Des Pharmaciens Du Canada : RPC 2013;146(6):335-41.
  2. Managing polypharmacy in a 77-year-old woman with multiple prescribers. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 2013;185(14):1240-5.
  3. Identifying and managing drug-related causes of common geriatric symptoms. Canadian Family Physician Medecin De Famille Canadien, 2014;60(2):147-53.

International Progress

  • The Australian Deprescribing Network (ADeN) consists of clinicians and researchers with an active interest in deprescribing and comprises geriatricians, general physicians, general practitioners, clinical pharmacists, clinical epidemiologists and a health economist. It features representation from tertiary and primary care, quality use of medicine agencies, including the National Prescribing Service (Australia), and guideline developers. The Network was established at a workshop held in Brisbane on May 20, 2014 and it seeks to lessen the iatrogenic drug burden in older patients on a national scale. 
  • For more information on ADeN, contact Dr. Ian Scott, Director of Internal Medicine and Clinical Epidemiology, Queensland University, at ian.scott@health.qld.gov.au.
  • Emily Reeve (School of Pharmacy and Medical Sciences at the University of South Australia) and her team recently published a paper on deprescribing in the March 2014 edition of the British Journal of Pharmacology
    • Reeve, E., Shakib, S., Hendrix, I., Roberts, M. S., & Wiese, M. D. (2014). Review of deprescribing processes and development of an evidence based, patient-centred deprescribing process. British Journal of Clinical Pharmacology (2014) doi:10.1111/bcp.12386

Fun Facts

  • While not yet incorporated into an official English dictionary, the term “deprescribing” is catching on.
  • Deprescribing produces 8,000 search results in Google; Prescribing produces 31 million. More work is needed!

Deprescribing Team Update

  • Congratulations to Hannah Irving, our Deprescribing Project Manager, who gave birth to a beautiful baby girl, Fiona, on June 3, 2014. During her maternity leave, Lisa Pizzola will take over the role of Project Manager, bringing with her the experience gained in coordinating development of the PPI Deprescribing Guideline.
  • We are pleased to welcome Lindsay Anderson, Hillary Bernosky, David de Launay, and Khaled Eid to our summer team!
    • Hillary & Khaled are second year pharmacy students at the University of Waterloo. Lindsay is a second year medical student at the University of Ottawa, and David is a BSc (Psychology) student at the University of Ottawa.
    • Read more about their backgrounds at www.open-pharmacy-research.ca

Keep in Touch

Follow us on Twitter: @Deprescribing
Contact us: deprescribing@bruyere.org
Check us out online: http://www.open-pharmacy-research.ca 
Contribute to our Wikipedia page: search ‘deprescribing’

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Copyright © 2014 Bruyere Research Insitute, All rights reserved.

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"Clipboard" designed by Scott Lewis from The Noun Project
"Conversation" designed by Marcio Duarte from The Noun Project