Marcia Frellick

May 19, 2017

SAN ANTONIO — An intervention in which Canadian pharmacists faxed their opinions about benzodiazepine use in older adults to physicians resulted in twice the number of deprescriptions as patient education alone, according to early data from the randomized controlled D-PRESCRIBE trial.

"In Canada, about two-thirds of those aged 65 and up take at least five medications daily, and one-quarter take at least 10 medications," said investigator Philippe Martin, a PhD student in pharmaceutical sciences at Université de Montréal.

Appropriate medication use is a top target in geriatrics, and healthcare in general. One of the main concerns is potential adverse effects, which are compounded by the polypharmacy common in older adults.

The focus of D-PRESCRIBE was benzodiazepines "because they are the most prominent inappropriate prescription, even though the side effects have been known for a long time. And it is one of the hardest classes of drug to deprescribe," Martin explained here at the American Geriatrics Society 2017 Annual Scientific Meeting.

The trial grew out of the randomized EMPOWER trial, which was designed to educate older adults about the potential risks and harms of benzodiazepines (JAMA Intern Med. 2014;174:890-898), in the hope that patients would become "a catalyst for deprescribing inappropriate benzodiazepines," Martin told Medscape Medical News.

The EMPOWER intervention involved an eight-page brochure, written at a low-literacy level in large font. In addition to risks and harms, the brochure suggested alternative drugs and offered a tapering-off schedule, designed to encourage patients to discuss discontinuation with a pharmacist or healthcare provider.

Six months after the intervention, a discontinuation rate of 27% was achieved, reported Martin, who was one of the EMPOWER investigators.

However, the researchers discovered that there was often resistance from physicians when patients approached them with the information, because physicians often were unaware of the risks or did not have an alternative drug to prescribe, Martin explained.

For that reason, he and his colleagues developed the D-PRESCRIBE trial, which added an evidence-based opinion from a pharmacist faxed to the patient's physician.

Participating pharmacists still gave patients the educational brochure used in the EMPOWER trial, but they also faxed evidenced-based pharmaceutical opinions to prescribers outlining the potential risks of benzodiazepines and encouraging deprescription.

Patients, pharmacists, physicians, and evaluators were blinded to the research.

Physicians could quickly change a prescription by writing their license number on the fax, signing it, and returning it to the pharmacist.

The main outcome of D-PRESCRIBE was discontinuation of benzodiazepines at 6 months that was sustained for at least 3 months. The researchers determined this by reviewing pharmacy renewal profiles.

The deprescription rate was higher in D-PRESCRIBE than in EMPOWER (odds ratio, 2.17; 95% confidence Interval, 1.21% - 3.67%).

"By sending out the opinions, we provided physicians with the proper tools to be more educated when their patients came in asking about deprescribing," Martin said.

Having the pharmacist connect with the doctor is a very smart idea.

The pushback seen in Canada from physicians who received notes from pharmacists would likely also happen in the United States, said Rosanne Leipzig, MD, PhD, vice chair of education for the Brookdale Department of Geriatrics and Palliative Medicine at the Mount Sinai School of Medicine in New York City.

"I think there's an overload feeling in this country by physicians, with everyone telling them what to do," she told Medscape Medical News.

However, with the current increase in multidisciplinary teams, there might be less resistance now than there would have been years ago, she pointed out.

"I don't know how it would fly here, but it's certainly worth trying," she added.

The brochure is well designed, and gets people to understand that what they think is helping them might actually be hurting them, she explained.

"And they got a great response," she noted. "Having the pharmacist connect with the doctor is a very smart idea."

As you get older, you will also have more side effects.

Benzodiazepines are extremely hard to get patients off of, said Dr Leipzig, and deprescribing takes months and often involves withdrawal.

"As you get older, you will also have more side effects. That's hard to explain to people who have been on them for a long time and haven't had any problems," she added.

The D-PRESCRIBE trial is ongoing. At the beginning of the trial, the study involved 46 pharmacies, but that number has grown to more than 90. Data gathering will likely be completed by the end of the summer, Martin reported, and results will likely be published by the end of the year.

The team is expanding their work to include widely prescribed drug classes that meet the Beers criteria for inappropriate use in older adults, such as first-generation antihistamines and nonsteroidal anti-inflammatory drugs, he added.

Mr Martin and Dr Leipzig have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. Presented May 18, 2017.

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