What is deprescribing?

As people get older or their health conditions change, certain medications become unnecessary or even harmful and contribute to polypharmacy. When clinicians reduce or stop such medications according to recommended guidelines it is called deprescribing. A multidisciplinary group of researchers and clinicians in Ottawa, Canada is leading the way on using decision aids to guide the process. Find more detailed info here.

This is a brief summary of 5 major categories of medications that your provider could deprescribe, or that you may wish to ask about. It is no surprise that 3/5 are medications that work directly in the brain, which is most at risk for serious harm.

Proton Pump Inhibitors (PPI’s)
Examples are omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), and esomeprazole (Nexium).

These drugs are most commonly prescribed for gastro esophageal reflux disease (GERD) or heartburn but are overused in record numbers for vague or minor stomach discomfort. PPI’s block acid production, a healthy mechanism that nature gave us to absorb nutrients and kill germs. This is why PPI’s are generally intended for short-term use (4-8 weeks) with noted exceptions of Barrett’s esophagus or severe esophagitis. Unfortunately through a series of factors, including heavy direct-to-consumer advertising, there is a high prevalence of long-term use. This is compounded by over-the-counter availability and a false presumption of harmlessness. Chronic use is associated with diarrhea (including Clostridium Difficile infection), kidney problems, impaired vitamin absorption, hip fractures, and pneumonia, all of which can be serious if not lethal in older or compromised individuals. This class of drugs was never intended (except may be by the marketers…) to be used for long periods of time.

Antihyperglycemics for diabetes
Examples are insulin and glyburide.

Some older adults benefit from less intensive blood glucose control because they experience frequent or serious side effects of low blood sugar, or their regimens are too burdensome. Stopping, reducing or switching agents can dramatically improve quality of life (including lessening the need for finger sticks) when tight glucose control is not indicated.

Examples include Seroquel (quetiapine), Risperdal (risperidone) and Zyprexa (olanzapine).

These drugs gained popularity for use in dementia when they first came out (despite having an FDA indication only for schizophrenia and bipolar disorder) because they were illegally marketed to “ease behavior problems in elders.” All three companies paid large fines for their crimes, but the medications continued to be prescribed. Older drugs like Haldol (haloperidone) pose even greater risks.

This class of medication is sometimes used to help with sleep or behavioral disturbances of dementia, despite posing dangerous risks (including stroke and death) having no FDA indication, and having little chance of actually being helpful. In cases of severe aggression, paranoia or frightening hallucinations, their use may be warranted to improve safety and distress, but the risk/benefit should be reassessed often. Antipsychotics have been significantly over-prescribed, especially in nursing homes, which are now required to monitor all psychotropics and perform Gradual Dose Reductions (GDR’s) on a regular basis.

Benzodiazepine receptor agonists
Sedatives and hypnotics include medications like Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam) and Ambien (zolpidem).

This class of drugs increases the risk for falls, confusion, dementia, daytime sedation and impaired driving. These medications also cause physical and psychological dependence so should be tapered off slowly and under supervision. Behavioral therapy, when combined with healthy sleep habits, is safer and more effective than medications for chronic insomnia.

Cholinesterase Inhibitors and Memantine
Examples of dementia medications include Aricept (donepezil) and Namenda (memantine).

They were approved not because they make dementia better, but because they slowed the progression of disease by a few months. Side effects include dizziness, confusion, insomnia, weight loss and falls. Once further decline becomes obvious it is unlikely that these medications are helping, and they may be hurting. Dementia medications should be tapered over several weeks (lowest doses) to months before stopping, and it is important to know that there is sometimes a brief period of worsened confusion that goes away after a few days.

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