Are Guidelines Part of the Problem?
Medscape: Many clinical guidelines have stressed the need for multiple drug regimens to achieve treatment goals. How much has this contributed to the apparent need for deprescribing in so many older patients now, and can it be prevented in future?
Dr. Scott: One thing that the literature has revealed over the past decade is that we have become used to being fairly aggressive in our therapy -- treating to target, wanting to ensure that we get everyone's blood pressure down to 130/80 mm Hg or everyone's HbA1c down to 7% or less -- and we assumed that the benefits that were seen in younger patients as a result of such an aggressive approach would extrapolate to older patients. There were clinical trials that suggested that high systolic blood pressure in elderly people needed to be lowered,[25,26,27,28] but I believe that we have gone a bit too far in one direction and become too aggressive.
As a result, recent trials suggest that in older people particularly, you can be a little more liberal in your target and achieve the same outcome; in fact, they do better.[29,30,31] The ADVANCE[32] and ACCORD[33] trials showed that if you lowered HbA1c below 7% in older patients with diabetes, it did not significantly reduce cardiovascular events, and in the ACCORD trial, intensive therapy was associated with increased mortality.[33] So now people realize that an HbA1c of 8% or even 8.5% is probably fine in people older than 70 years,[34] and that is what we should stick to.
As another example, there is a big debate on statins in Australia at the moment and whether in older people who have had a past small infarct, megadoses of statins are beneficial when considering the potential side effects. In terms of drug use, we should follow the old dictum that in older people, we should "start low and go slow," and in some cases we need to cease them. That is probably the next step, so that we start low, go slow, and then stop if the drug is not working.
Medscape: So you are really talking about a kind of culture change?
Dr. Scott: We have to introduce an agenda where first of all, we have informed patients who are a little more critical and ask questions about why they should be taking a lot of different drugs and what the benefits and harms may be. That is the first step: to have a more questioning, informed public, so that doctors are put a little more under the microscope in relation to drug prescribing.
The second step should be to empower general practitioners and general specialists to be a little more critical of their specialty colleagues and ask them, quite pointedly in some cases, to justify why they want to prescribe this or that drug. That takes a bit of culture change, but it is coming, and the public is becoming more aware of this problem and I feel quite sure that the next generation of patients will be more questioning than this generation.
Medscape: Is it really going to take that long to bring about a change in practice?
Dr. Scott: It is going to take a generation to bring it about, because not only have doctors -- and, thus, to some extent patients -- been indoctrinated over the past 20 years with "more is better" (eg, more pills are good for you), but we also have a pharmaceutical industry that is clearly not going to be keen on deprescribing, because it means less revenue for them. So there are some vested interests that are not going to accept this argument very easily.
Nevertheless, I believe that governments and health fund payers are going to take an interest, because they are paying for the ADRs and the hospitalizations that result from polypharmacy, and they will bring pressure to bear to make clinicians more aware of this problem and what they should be doing about it.
Medscape: Are you optimistic that this will happen eventually?
Dr. Scott: There is now a lot more about this in the literature, so there appears to be a growing realization that it is a problem. What holds us back is that people are saying yes, in principle, we should be prescribing fewer drugs, but they are discouraged by the practicalities of how to go about it.
We are currently working on a number of projects in residential care facilities, primary care practices, and hospitals aimed at assisting doctors to apply our algorithm in a practical way. We are doing some validation studies of the algorithm right now to see how feasible and how useful it is, so watch this space.
By the end of 2013, we hope to have published some more reports that will reassure people that deprescribing can be undertaken in busy clinical settings. We are learning whether are there parts of the algorithm that we can shorten or make easier to apply, whether we need to apply all the 10 steps, or whether can we need only apply certain steps to specific populations. So I am hopeful that we will see people thinking more critically about polypharmacy and trying to stop some of these drugs in their patients.
Medscape: Do you think that after validation in Australia, your algorithm will be suitable for adoption globally?
Dr. Scott: I would like to think so.
Medscape Internal Medicine © 2013 WebMD, LLC
Cite this: Deprescribing in Clinical Practice: Reducing Polypharmacy in Older Patients - Medscape - Nov 26, 2013.
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