Can tools fix our polypharmacy problems?

As pharmacists, we are always looking for tools and resources that make our lives easier. When it comes to deprescribing, we hear about screening criteria.1 These are essentially lists of potentially inappropriate drugs that we can screen for in patients’ medication lists. Examples are Beer’s criteria2 and the STOPP criteria.3 Frameworks, which are generally a series of steps (each with associated guidance) that clinicians apply to an entire medication list, are also available.4 Several stepwise deprescribing processes or frameworks have been proposed. There are also patient education/engagement tools, guidelines for individual medications, and multifaceted tools that combine aspects of multiple types of tools.4 The various deprescribing networks across the world have compiled these tools on their websites (see Box 1). In this article, I reflect on some available deprescribing tools and their incorporation into practice. How effective are screening criteria?When it comes to deprescribing, a lot of people talk about screening criteria for potentially inappropriate medications (PIMs). Early in my practice doing medication reviews, I was hyperfixated on medications that appeared on these lists. Yet, one of the challenges with simply applying screening criteria is that we can lose sight of the patient in front of us and the actual clinical problems.5 This is reflected in available evidence. For example, only one in seven PIMs identified by screening criteria is clinically relevant.6 In randomized clinical trials (RCTs) testing screening criteria-driven medication reviews against usual care, most recommendations to stop PIMs were not implemented in practice.7 Further, screening criteria-driven interventions have not shown to lead to meaningful differences in patient outcomes in well-designed RCTs.8,9 This is not to say that screening criteria are never useful. They might be useful in creating awareness of deprescribing options. However, as the developers of such tools highlight, they should be applied with clinical judgement. If you’re doing a medication review, simply scanning the medication list to find medications that appear on a PIMs list is probably not good care.Common senseStepwise deprescribing frameworks follow a structured common-sense approach: identify medications a person is taking, assess the patient, identify deprescribing opportunities, prioritize medications for deprescribing, and develop/implement a plan.4 All of this should be done in collaboration with a patient/caregiver. Through assessment, and a conversation with a patient,10 we can identify clinically important problems that actually matter to patients. Asking patients about their experiences with, and response to, their medications can uncover things such as:Medications causing actual harm or with high potential for future harmMedications that are a burden or inconvenience to the patientMedications that are not effective or no longer necessaryFocusing on what matters to the patient!Application of a structured process by pharmacists and/or physicians does seem to reduce the number of medications (although its effect on other outcomes is less clear).11,12 One challenge is that stepwise processes can be very open-ended and might require advanced knowledge or expertise to implement effectively. Stepwise processes generally don’t contain much guidance about how to practically stop an individual medication (e.g., how fast to taper, whatto monitor for). They may also be time-consuming to implement. However, as a general approach, incorporating these stepwise frameworks appears to be a patient-centred approach to deprescribing that allows for a focus on clinically relevant problems.Supporting toolsTools can be used to augment and support a commonsense approach. For example, if together with a patient you decide to stop a specific medication, drug-specific deprescribing guidelines (see Box 1) are available to help with decisions and planning. Further, if you are trying to prioritize medications for deprescribing, patient education or engagement materials could be useful in guiding decisions.13 Ideally, choose education or engagement materials that are evidence-based, have been peer-reviewed and use patient-friendly language. The Canadian Medication Appropriateness Network and Choosing Wisely Canada have a number of patient engagement materials available (see Box 1).New approachesAutomation and integration of one or more deprescribing tools into electronic medical records and existing workflow is hoped to make the process more practical and simpler in the real-world.4 This approach might address some of the time and workflow barriers that exist with manual application of tools. So far, there have been mixed results from RCTs that have tested electronic decision support tools. A challenge is that simply automating screening criteria may not escape their limitations in the first place. Integration of more patient-centred inputs, such as symptom priorities and goals of care, may help improve the clinical relevance of automated tools. This is being examined by tools such as TaperMD.14SummaryUltimately, tools in isolation are likely not going to solve all our polypharmacy problems. But tools can support different parts of the deprescribing process—such as identifying deprescribing opportunities, patient engagement, and developing drug-specific deprescribing plans—as long as the focus is always on the individual patient.Wade Thompson is a pharmacist and researcher working to ensure older persons are taking medications that are necessary, effective, safe, and consistent with their healthcare goals and treatment preferences. He is an assistant professor in the Department of Anesthesiology, Pharmacology and Therapeutics in the Faculty of Medicine at the University of British Columbia. He is an investigator with deprescribing.org and a member of the Therapeutics Initiative, and works clinically as a pharmacist in long-term care.References:Masnoon N, Shakib S, Kalisch-Ellett L, et al. Tools for assessment of the appropriateness of prescribing and association with patient-related outcomes: a systematic review. Drugs Aging 2018;35(1):43-60. doi:10.1007/s40266-018-0516-8.American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-81. doi:10.1111/jgs.18372.O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med 2023;14(4):625-32. doi:10.1007/s41999-023-00777-y.Reeve E. Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice. J Pharm Pract Res 2020;50(1):98-107. doi:10.1002/jppr.1626.Verdoorn S, Kwint HF, Faber A, et al. Majority of drug-related problems identified during medication review are not associated with STOPP/START criteria. Eur J Clin Pharmacol 2015;71(10):1255-62. doi:10.1007/s00228-015-1908-x.Parodi López N, Svensson SA, Wallerstedt SM. Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria—a validation study. Eur J Clin Pharmacol 2022;78(8):1331-9. doi:10.1007/s00228-022-03337-8.Dalton K, Curtin D, O’Mahony D, et al. Computer-generated STOPP/START recommendations for hospitalised older adults: evaluation of the relationship between clinical relevance and rate of implementation in the SENATOR trial. Age Ageing 2020;49(4):615-21. doi:10.1093/ageing/afaa062.O’Mahony D, Gudmundsson A, Soiza RL, et al. Prevention of adverse drug reactions in hospitalized older patients with multi-morbidity and polypharmacy: the SENATOR* randomized controlled clinical trial. Age Ageing 2020;49(4):605-14. doi:10.1093/ageing/afaa072.Blum MR, Sallevelt BTGM, Spinewine A, et al. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. BMJ 2021;374:n1585. Published online July 13, 2021:n1585. doi:10.1136/bmj.n1585.Farrell B. Engaging patients in conversations about deprescribing. Expert Rev Clin Pharmacol 2024;17(5-6):419-22. doi:10.1080/17512433.2024.2343913.Page AT, Clifford RM, Potter K, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol 2016;82(3):583-623. doi:10.1111/bcp.12975.Ibrahim K, Cox NJ, Stevenson JM, et al. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr 2021;21(1):258. doi:10.1186/s12877-021-02208-8.Fajardo MA, Weir KR, Bonner C, et al. Availability and readability of patient education materials for deprescribing: an environmental scan. Br J Clin Pharmacol 2019;85(7):1396-406. doi:10.1111/bcp.13912.Mangin D, Lamarche L, Agarwal G, et al. Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy. Pilot Feasibility Stud 2023;9(1):84. doi:10.1186/s40814-023-01315-0.

Can tools fix our polypharmacy problems?

Register for free access or login.

More Blog Posts in This Series

Where to start?

Engaging patients: your words matter

Deprescribing: finding the best fit for individual patients

Blog Author

WADE THOMPSON

Related Topics