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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018
| Contributor Information
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
The Polypharmacy Problem
Polypharmacy is described as taking five or more medications daily.[1] One survey found that more than 50% of female Medicare beneficiaries took five or more medications daily, with 12% taking 10 or more medications daily.[2]
Overprescribing in the elderly is concerning. A study found that prevalence of polypharmacy increased from 17.8% to 60.4% in patients ≥ 65 years between 1997 and 2012.[3]
11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
There is no evidence that docusate (Colace®) is effective for what it is used for—softening the stool or preventing constipation. In a randomized controlled trial, 170 adults with chronic constipation received either 5.1 g psyllium or 100 mg docusate twice daily.[4] Psyllium was safe and superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33% vs .01% for docusate (P = .007), and stool weight was increased in the group treated with psyllium (359.9 g weekly vs 271.9 g weekly from docusate-treated patients; P = .005).
A study conducted in cancer patients compared those treated with a combination of the stimulant laxative sennosides and docusate to those treated with docusate alone.[5] Patients were followed for almost 500 days. The senna-only group had more frequent bowel movements, with no difference in amount of reported cramping compared with the group taking the combination.
Docusate probably continues to be overused and is a contributor to polypharmacy. A cohort study found that one third of patients admitted to an internal medicine floor who were not taking docusate at the time of admission were discharged with a docusate prescription.[6]
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
Following changes to the antibiotic prophylaxis guidelines for prevention of endocarditis in 1997,[7] clinicians should be prescribing far fewer antibiotics as prophylaxis before dental cleanings or procedures. Many patients are still receiving antibiotic prophylaxis before dental procedures because they have prosthetic joints,[8] even though there is no evidence to support this practice, and the most recent American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) recommendations do not encourage it[9]; the organizations have developed joint Appropriate Use Criteria for this population.[10] In 2015, the ADA guidelines specifically recommend against this practice.[11] This advice may not apply to transplant patients, and the decision to premedicate for invasive dental procedures and selection of the appropriate regimen should be made on a case-by-case basis.[12]
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
Among the potential problems associated with proton pump inhibitors (PPIs) are reduced absorption of calcium (with increased fracture risk), B12, and thyroid hormone absorption, acute and chronic kidney injury, and increased risk for Clostridium difficile infection. Mortality may also be increased in PPI users.[13] Some patients do need PPIs long-term (eg, refractory reflux disease, scleroderma-related reflux, and elderly patients on chronic nonsteroidal anti-inflammatory drug therapy). However, many other patients are prescribed PPIs. They are often prescribed for stress ulcer prophylaxis in hospitalized patients but aren't needed after discharge. Another common use of PPIs is for abdominal pain without a recognized source; in this situation, it makes sense to try taking the patient off of the PPI. The data on the benefits versus harms of deprescribing PPIs are inconclusive. A Cochrane review[14] found that deprescribing PPIs can increase gastrointestinal symptoms while reducing pill burden.
11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
With the release of the American Heart Association guidelines for statin use in 2013,[15] there has been a significant increase in the use of statins for primary prevention, but there is a paucity of evidence on the benefits of statins for primary prevention in patients over the age of 75 years.[16,17] A large observational study conducted in patients over the age of 75 found no benefit in atherosclerotic cardiovascular disease (CVD) or all-cause mortality in nondiabetic adults aged 75 and older. Even for those with diabetes, there was no benefit found in patients over the age of 85.
The Choosing Wisely campaign has issued a statement on statins in those over age 75, saying there is "no clear evidence that high cholesterol leads to heart disease or death" in this population, and that some studies show that people with the lowest levels of cholesterol have the highest risk for death. Statins can be associated with muscle symptoms and can interact with several drugs, increasing toxicity in elderly patients. There is a difference in the potential benefits of statins for secondary (after cardiovascular event or stroke) versus primary prevention. The risks versus benefits of primary prevention is a particular concern in patients over the age of 80.
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
Insomnia, a common concern in older patients, is often managed pharmacologically, but the chronic use of benzodiazepines and the "Z drugs"—zolpidem, zaleplon, and eszopiclone—should be avoided. In elderly patients, the risk of stacking of side effects and risks is very real. Many elderly patients are on selective serotonin reuptake inhibitors (SSRIs) and may also be taking a benzodiazepine to treat the insomnia caused by the SSRI. All three of these drug groups—benzodiazepines, SSRIs, and Z drugs—raise the risk for falls in the elderly.[18]
11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
In the 2011 American Heart Association/American College of Cardiology Foundation guidelines,[19] beta-blocker use was recommended for 3 years after either a myocardial infarction (MI) or acute coronary syndrome (ACS) in all patients with preserved left ventricular function (class I recommendation, grade B evidence). As a class IIa recommendation, the guidelines stated that it was reasonable to continue beta-blocker therapy beyond 3 years in patients with a history of MI or ACS. More recent data have not shown long-term mortality benefit with prolonged beta-blocker use and call into question the immediate benefit of beta-blockers after MI or ACS in an era when reperfusion therapies are common.[20,21] Furthermore, beta-blockers are not very potent antihypertensive agents and are less effective than other options for the treatment of hypertension in the elderly.[22] Atenolol is particularly ineffective for prevention of negative outcomes from hypertension.[23]
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
Many patients with shortness of breath are diagnosed with asthma or chronic obstructive pulmonary disease (COPD), and when their symptoms do not resolve, more drugs and higher doses are prescribed.
In a recent study,[24] one third of patients with a current diagnosis of asthma had normal respiratory tests (spirometry/peak flow) and had no problems with weaning off of asthma medications. The same high rate of incorrect asthma diagnosis has been shown in several other studies over the past few years.[25,26] The major culprit in misdiagnosis was not using spirometry to make the diagnosis.
This is a good area in which to practice deprescribing. Some patients with asthma or COPD are misdiagnosed, others may not have active asthma, and medications could be weaned.
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
The antimuscarinic agents (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium) used commonly for the treatment of stress urinary incontinence have a small benefit.[27] These drugs have strong anticholinergic properties and can cause major side effects, especially in elderly populations; the Beers criteria describes this class of drugs as potentially inappropriate for use in the elderly. For example, oxybutynin resolved urinary incontinence in 114 of 1000 treated patients, while 63 of 1000 stopped treatment because of side effects.[28]
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
This is another drug class with very modest benefit and many disconcerting side effects. The number needed to treat for any benefit in patients with dementia for donepezil (the most commonly prescribed anticholinesterase inhibitor) is 12.[29] This means that for every patient who obtains a modest benefit from this drug, 11 will be treated but have no benefit. The side effects are disturbing with this class of drugs and include nausea, decreased appetite, weight loss, syncope, and urinary incontinence.[30,31] Some patients may even be started on an antimuscarinic agent for the urinary incontinence caused by the anticholinesterase inhibitor they are taking.
11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
The evidence of benefit is insufficient for the use of muscle relaxants for the treatment of subacute or chronic low back pain.[32] This class of medications produces a great deal of side effects and is especially dangerous in the elderly, as evidenced by its categorization as potentially inappropriate in the Beers criteria. Toxicity is increased when combined with alcohol.
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11 Drugs You Should Seriously Consider Deprescribing: 2018 Update
Douglas S. Paauw, MD | November 5, 2018 | Contributor Information
Many patients take over-the-counter supplements. In fact, many doctors and nurses take—and recommend—supplements.[33] Taking supplemental vitamins is particularly common, although no benefit has been shown in cardiovascular disease or, in the case of vitamin D, cancer prevention.[34] Calcium supplements are also unlikely to benefit postmenopausal women. In the largest study to date, calcium and vitamin D supplementation slightly increased bone density and frequency of kidney stones but did not reduce fracture risk.[35] Calcium supplementation does inhibit thyroid hormone absorption.
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Contributor Information
Author
Douglas S. Paauw, MD
Professor of Medicine
Rathmann Family Foundation Endowed Chair for Patient-Centered Clinical Education
University of Washington School of Medicine
Seattle, Washington
Disclosure: Douglas S. Paauw, MD, has disclosed no relevant financial relationships.
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