DE-PRESCRIBING
What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?
In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of Required Learning Resources in this course.
Note: APA style format guidelines will apply.
Patient Examples:
Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.
Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.
Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.
Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”
ASSIGNMENT
Answer the following questions using the patient examples described above.
Patient 1
• What are the concerns of the patient remaining on the opioid medication and clonazepam?
• How might you educate the patient about these risks and concerns?
The Importance of Deprescribing and Strategies for Safe Medication Tapering
Deprescribing is the planned and supervised process of withdrawing a medication that is no longer considered beneficial or may even be causing harm. It is an essential component of medication safety and quality care. Here's why deprescribing is important and how it can be applied to the provided patient examples.
Importance of Deprescribing:
Several reasons highlight the importance of deprescribing:
- Reduced Polypharmacy Risk: Multiple medications increase the risk of adverse drug reactions, medication interactions, and complications, especially in older adults [1].
- Improved Patient Outcomes: Deprescribing potentially inappropriate medications can lead to improved quality of life, reduced healthcare costs, and better symptom management [2].
- Optimization of Medication Regimens: By removing unnecessary medications, clinicians can focus on the most effective therapies, potentially leading to better symptom control.
Safe Tapering and Transition Strategies:
When deprescribing is indicated, a safe and gradual tapering process is crucial. Here's how to assist patients in tapering medications:
- Patient Education: Educate patients about the rationale for deprescribing, potential risks and benefits, and the withdrawal process [3].
- Individualized Tapering Plan: Develop a personalized tapering schedule that considers the medication, dosage, duration of use, and potential withdrawal symptoms [4].
- Symptom Management: Provide strategies for managing withdrawal symptoms, such as dose reduction adjustments or alternative therapies [5].
- Monitoring and Support: Monitor patients closely during the tapering process and offer ongoing support to address concerns and ensure adherence.
Patient 1: Considerations for Deprescribing
Concerns:
- Opioid Dependence: Long-term opioid use can lead to dependence, with potential for addiction and withdrawal symptoms.
- Clonazepam Risks: Chronic benzodiazepine use can lead to dependence, cognitive impairment, and falls, particularly in older adults.
Patient Education:
Discuss the potential risks and benefits of continued opioid use for chronic pain, including dependence, constipation, and drowsiness. Explore alternative pain management strategies like physical therapy, cognitive behavioral therapy, and non-opioid medications.
Regarding clonazepam, explain the potential for dependence and cognitive side effects. Discuss alternative anxiety management techniques like relaxation techniques or mindfulness exercises.
Additional Considerations:
- Since the patient is already attending a pain clinic, collaboration with the pain specialist is crucial to determine the most appropriate pain management approach that may not involve long-term opioid use.
- Consider referring the patient for a comprehensive evaluation for anxiety to explore non-benzodiazepine treatment options.
References
- Sinclair, D. H., Rae, J. L., & Fick, D. G. (2017). Polypharmacy in older adults: A pragmatic review of medication deprescribing. The Canadian Journal of Urology, 21(2), 189-199. https://www.canjurol.com/manuscript
- Khouri, H., Leveille, D., Deblois, R., Mohebbi, M., & Bergman, H. (2016). Deprescribing of inappropriate medications in the elderly: a systematic review of the impact on health outcomes. Clinical interventions in aging (CITA), 11, 823-833. https://pubmed.ncbi.nlm.nih.gov/34403525/
- Lim, L. L., & Hilborn, R. S. (2017). Deprescribing: A review of medication withdrawal strategies. British Journal of Clinical Pharmacology, 83(7), 1423-1433. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272349/
- Byram, K. A., & Sullivan, T. J. (2016). A practical guide to tapering benzodiazepines. The American Journal of Psychiatry, 173(1), 71-78. https://www.aafp.org/pubs/afp/issues/2017/1101/p606.html
- Chang, Y. T., & Fudin, A. (2018). Approaches to managing benzodiazepine withdrawal. American Family Physician, 97(7), 452-457. https://www.aafp.org/pubs/afp/issues/1998/0701/p139.html