Transcript Issues at the end-of-life

Deprescribing at the End-of-Life:
Less is More
James B. Ray, PharmD, CPE
The James A. Otterbeck Professor of Hospice & Palliative Care
University of Iowa College of Pharmacy
[email protected]
11/18/2015
Brief background - definitions and statistics
• Deprescribing – systematic process of identifying and
discontinuing drugs in instances in which existing or
potential harms outweigh existing or potential benefits
in the context of an individual patients’ care
CASES –
• Packet of patient cases
• Task
– Identify which medications you would
deprescribe
– Share rationale
– Prioritize….which would you DC first?
Treatment Target
Goals of Care
Time Until Benefit
Remaining Life Expectancy
Goals of Care
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Clinical judgement and patient guided decision making
– Ongoing discussion
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Standards of care and practice guidelines can be
momentarily forgotten
Statins
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Hyperlipidemia increases with age
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However, very old, severely ill patients, and actively dying patients may
having declining LDL and TC levels
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Too low of TC may be a marker of poor outcomes
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Time-to-benefit for statins – 2-6 years
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Burdens of statins:
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Myopathy and myalgias
Fatigue
Pill burden
Lab testing
Cost
http://www.cliparthut.com/sleeping-with-woman-at-desk-clipart.html
Bisphosphonates
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Proven benefit for fracture prevention in osteoporosis and for women on anti-estrogen
therapies
Correct duration of therapy is unknown
Risks of bisphosphonates include:
• Short term
» Headache, dyspepsia, abdominal pain, gastrointestinal ulcers, muscle cramps
• Long term
» Bone fractures, chronic bone/joint/muscle pain, osteonecrosis of the jaw,
severe hypocalcemia
• Issues at the end-of-life
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Administration
Cost
Adverse effects
Quality of life
Extended efficacy?
http://www.myfamilymeddocs.com/service/osteoporosis/
Anti-hypertensives
• Primary prevention of cardiovascular disease and kidney disease
• BP is used as a surrogate marker for control
• Guideline driven care with specific BP targets – often >1 drug
• Issues at the end-of-life
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Fatigue
Hypotension
Orthostasis
Falls
Cognitive impairment
The how?
Evidence-based recommendations:
How do I stop it?
Benzodiazepines
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If used daily for more than 3-4 weeks then:
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Reduce dose by 25% every week (i.e. week 1-75%, week 2-50%, week
3-25%)
•
If intolerable withdrawal symptoms occur (usually 1-3 days after a dose
change), go back to the previously tolerated dose until symptoms
resolve and plan for a more gradual taper with the patient
•
Dose reduction may need to slow down as one gets to smaller doses
(i.e. 25% of the original dose)
•
The rate of discontinuation needs to be controlled by the person taking
the medication.
Benzodiazepines
• Symptoms to monitor for:
– Rebound insomnia
– Tremor
– Anxiety
– Hallucinations
– Seizures
– Delirium
Opioids
• If used daily for more than 3-4 weeks then:
• Reduce the dose by 25% every 3 to 4 days
• Once at 25% of the original dose and no withdrawal symptoms have
been seen, stop the drug
• If any withdrawal symptoms occur, go back to approximately 75% of
the previously tolerated dose.
Opioids
• Symptoms to monitor for:
– Restlessness
– Runny nose
– Goose flesh
– Sweating
– Muscle cramps
– Insomnia
– Pain
– Secretion of tears
– Dilation of the pupils
– Breathlessness
– Decrease or impairment in daily function
Beta Blockers
• If used daily for more than 3weeks:
– Reduce dose by 50% every 1 to 2 weeks (7-10 days)
– May stop once at 25% if not symptomatic
– Metoprolol and atenolol
• Symptoms to monitor for:
– Chest pain
– Pounding heart
– Blood pressure – does it need to be re-measured?
– Anxiety
– Tremor
http://thinkprogress.org/health/2013/01/31/1517821/fetal-heartbeat-bills-to-watch/
Clonidine
• If used for >1 week:
– Reduce dose by 50% every week
– May taper over 2-4 days
– Oral versus patch?
• Symptoms to monitor for:
– Rebound hypertension
– Headache
– Insomnia
– Tachycardia
– Hiccups
– Salivation
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=20848
Anti-depressants
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Depends on the agent!
– Paroxetine and venlafaxine
– Fluoxetine
•
Taper over several months – reduce the dose by 25% every 4 to 6 weeks
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Symptoms to monitor for:
– Insomnia
– Flu-like symptoms
– Imbalance
– Sensory experiences (electric shock-like feelings)
– Hyperarousal
– N/V/D
– Agitation
Baclofen
• Taper over 2-4 weeks
• Decrease dose by 25% every week
• Symptoms to monitor for:
– High fever
– Altered mental status
– Muscle rigidity
– Muscle cramps and pain
• Re-initiate therapy if symptoms are intolerable at 75% of the
original dose
Others
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Tizanidine
Corticosteroids
Anti-psychotics
Gabapentin
Anti-epileptics
Carisoprodol
Nitrates
Be an advocate for your patients
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Help patients understand WHY a medication may not be
appropriate any longer
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Discuss how they may feel after stopping the medication
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Tell them HOW you are going to stop the medication
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WHAT are you going to do if symptoms come back?
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Use conversation to help understand your patient’s
treatment target, goals of care, and overall wishes about
medications