Friday, September 20, 2013

Australians Don't Like Polypharmacy, What About You?

Patients attending an ambulatory consulting service in Adelaide, Australia were queried regarding their feelings about stopping medications, and the results were reported in JAGS recently.  The subjects, age 71 on average, were taking an average of ten medications.  Most subjects thought they were taking a "large number" of medications and 92% said they'd be willing to stop one or more medication "if possible."
Licorice Bridge Mix?
Big shocker for Pallimed readers, I'm sure. Who wants to take ten medications?

This survey included a geriatrics population and was published in a geriatrics journal.  But if you practice palliative care or see patients with limited prognoses, you should take heart in the notion of slashing medication lists, especially when you can see no clear indication for the medications.  I'm looking at you, primary and secondary preventative medications. 

A few hypotheses for why it's so difficult for some physicians to discontinue medications:

  1. Inertia:  It's easier to continue with the status quo.
  2. It may require a discussion about overall prognosis:  "Wait a second, doc.  My doctors have been telling me for years to take that orange pill.  Are you sure it's OK to stop now?"  In other words, patients want to do the right thing, even if that means being burdened with taking a boatload of meds.  This is evidenced in the JAGS study by the fact that 71% of patients said they'd accept taking more medications, if necessary.  However, if a prognostic discussion has occurred (e.g. related to advanced cancer, etc), it's then easier to say "I think that medication has done it's job, I admire your commitment to taking it, and now it's OK to give it a rest."
  3. Overestimation of actual benefit of medications: "He had an NSTEMI five years ago.  What if we stop the simvastatin and he has another MI? Sure, he's probably going to die from lung cancer in the next several months, but I don't want him to die from an MI. No, he's not having any coronary artery disease symptoms now, but I think it's best just to continue it."   Look at a meta-analysis of several studies evaluating the benefit of statins for primary and secondary prevention of cardiovascular events.  The number needed to treat to prevent one major coronary event was 28, which isn't horrible.  Yet it's not exactly dooming your patient to angina/MI before he dies, especially if you consider that the five studies evaluated in the meta-analysis followed patients for 5-6 years to look for the outcomes. 
I'm always careful to decide whether discontinuation of medications is within my purview as the palliative care consultant.  Is the patient burdened by the polypharmacy?  Do they have dysphagia?  Are they having side effects?  Are you concerned about interactions with other, more important medications?  Is the patient or family having trouble obtaining medications? Does it just plain not make sense for the medication to be continued because of the patient's prognosis?   If the answer is yes to any of these questions, I think it's well within your purview to recommend discontinuation, even if it's an unexpected recommendation from your referring physician.  In making the recommendation, I'd highlight the rationale from a palliative care standpoint.  Focus on the quality of life aspect. 

Use a shared decision-making approach with patients.  Even though it's OK to discontinue meds, it's also OK to not be dogmatic about it if the patient prefers to continue the med (as long as it's not harming them).

As hard as it is to stay on top of the deluge of new research (just even in your own specialty), it also never hurts to remain aware of research regarding the indications for primary/secondary prevention.  A good example would be a recent cohort study from the Annals of Internal Medicine which suggests the optimal BP in patients with chronic kidney disease may be 130 to 159/70 to 89 mm Hg, with patients in that group having lower mortality rates. 

If you're reading this, you're probably part of the choir already.  If so, here's a pat on the back to you for being vigalant about polypharmacy!

For more related to this topic, see my post from a few years ago about "Minimally Disruptive Medicine" (and some other related links in that post).   

Edit 9/22/2013:  Also, I just found some recent American data published in Journal of Palliative Medicine on statin use near the end of life in patients with cancer (along with a letter to the editor on the JPM study). Bottom line: Statin use common in this population right up until time of death, unclear how appropriate the use is in each individual patient, but opportunities to deprescribe were likely missed. 

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