The importance of de-prescribing

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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?

 

• How would you instruct the patient to taper off clonazepam?
• What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
• How would you start the new recommended psychotropic medication for the patient?
• Discuss one legal, ethical, or social consideration with the treatment plan.

Sample Solution

Importance of Deprescribing and Safe Tapering

Deprescribing is the planned and gradual reduction or discontinuation of a medication that is no longer considered beneficial or may even be causing harm. It’s a crucial component of medication management, promoting better patient outcomes by:

  • Reducing polypharmacy: This minimizes the risk of drug interactions and adverse side effects, especially in older adults (Sinclair et al., 2017).
  • Improving adherence: A simplified medication regimen is easier to follow, leading to better long-term health outcomes (Vrijens et al., 2016).
  • Addressing potential dependence: Deprescribing can help identify and manage medication dependence on opioids and benzodiazepines (Wang et al., 2013).

Safe Tapering and Transitioning:

Aiding patients in tapering off medications or transitioning to new ones requires a collaborative approach. Here’s how to support patients safely:

  1. Shared Decision-Making: Discuss the pros and cons of tapering and explore patient preferences.
  2. Individualized Plans: Develop a personalized tapering schedule based on the medication, duration of use, and potential withdrawal symptoms (Ashton, 2005).
  3. Patient Education: Inform patients about expected withdrawal symptoms and coping strategies (NICE, 2015).
  4. Regular Monitoring: Closely monitor patients for withdrawal symptoms and adjust the taper pace as needed.
  5. Alternative Therapies: Explore non-pharmacological options like cognitive-behavioral therapy (CBT) for anxiety management (Gould et al., 1997).

Applying Deprescribing to Patient Examples

Patient 1: Opioid and Clonazepam

Concerns:

  • Opioids: Long-term use can lead to dependence, constipation, drowsiness, and respiratory depression (Dowell et al., 2016).
  • Clonazepam: Combined with opioids, it increases the risk of respiratory depression. Additionally, long-term benzodiazepine use can lead to dependence, cognitive impairment, and falls (Sinclair et al., 2017).

Educating the Patient:

Explain the potential risks of both medications and collaboratively explore alternative anxiety management strategies. Resources like educational brochures can further empower the patient.

Tapering Clonazepam:

Develop a slow tapering schedule based on the current dose (1mg BID). Consider a 10-25% reduction every 2-4 weeks to minimize withdrawal symptoms (Ashton, 2005).

Alternative for Panic Attacks:

CBT can be a highly effective non-medication approach for panic attacks (Gould et al., 1997). Discuss the benefits of CBT and offer a referral to a therapist.

Starting New Medication:

If CBT is not preferred, consider a selective serotonin reuptake inhibitor (SSRI) like sertraline, which is less likely to interact with opioids (UpToDate, https://www.uptodate.com/login). Start at a low dose and gradually increase based on patient response and tolerability.

Legal/Ethical Consideration:

While tapering clonazepam is recommended, it’s crucial to respect patient autonomy. If the patient is hesitant, explore the risks further and document the discussion.

Remember, these are just general guidelines. Always consult with the patient’s primary care physician or pain specialist before making any medication changes.

 

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