Reducing Medications – Strategies I Routinely Use (Part 1)
In geriatrics, we put a premium on trying to simplify medication use. As a consultant pharmacist who has worked extensively in long term care and assisted living, I am routinely asked if we can reduce someone’s medications. Reducing medications is something I consider in virtually every patient I work with. Here
1. Duplicate Therapy
This is a pretty easy one. Recognizing what the mechanism of action of a drug is can help you identify areas of duplication. Examples I have come across include alpha blockers, inhaled medications (corticosteroids, beta agonists, etc.), antihistamines, and SSRI/SNRI combinations. There are rare circumstances where a duplication might make sense, but these are few and far between.
Supplements get a little more tricky. Working with families and caregivers who have strong beliefs about a supplement can be a challenging situation. A few common supplements that I will ask to discontinue in most situations include vitamin C, vitamin E, and other vitamins that may be found within a multivitamin. Iron, B12, and folic acid are supplements that are often prescribed and seldom reassessed. It is advisable to understand why they were prescribed and consider lab work to address whether they are needed long term or not.
3. Excessive Treatment
Statins and osteoporosis medications would be a couple of good examples of excessive preventative treatment in SOME patients. Patients with limited life expectancy are likely to not receive many benefits from these medications. Pain management is a situation which often gets aggressively managed. If one medication doesn’t work, another medication is tried, and so on… It is critical to reassess the medications that did not work or only provided minimal benefit. They can possibly be discontinued. In patients with advanced dementia, continuing their donepezil and memantine may be overkill as well.
4. Review of Symptoms
Elderly patients often have a large number of medications due to symptoms that are non-life-threatening. GI upset, neuropathy, RLS, insomnia, pain and IBS are a few examples that come to mind. When reducing medications, I look at drugs like PPI’s, H2 blockers, gabapentin, pregabalin, dopamine agonists, opioids, acetaminophen, dicyclomine, metoclopramide, melatonin, Z-drugs, and ondansetron. If the symptoms that these drugs treat are well managed, it is a strong consideration to try to reduce and/or discontinue these type of medications.
Assessment of behavioral symptoms and review of psychotropic drugs is something that you will do on a daily basis as a geriatric pharmacist. There are requirements for documentation of these drugs in long term care. I detail these in much greater depth in my Guide to Long Term Care Pharmacy Consulting.
I’ve got more strategies to come to try to reduce our patients’ medication load, stay tuned to the blog!
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