A computer-assisted workflow helps pharmacists deprescribe medications that patients no longer need after leaving the ICU, researchers reported in the Journal of the American College of Clinical Pharmacy (2023 Jul 21. doi:10.1002/jac5.1861).
Acid-suppressing medications such as proton pump inhibitors or histamine-2 receptor blockers are often prescribed in ICUs to reduce the risk for stress ulcer–related bleeding. But many patients continue these medications after they have stabilized and left the ICU.
Prolonged use of acid-suppressing medications “has been linked to a number of complications, including infections and nutrient deficiencies,” said Lauren Kimmons, PharmD, a clinical pharmacy specialist in critical care at Methodist University Hospital, in Memphis, Tenn. To address this problem, she and her team integrated pharmacist oversight into transitions of care (TOC) from the ICU into the general hospital.
“Fortunately, we have great trust from our hospital providers, and our scope of practice allows pharmacists to modify or discontinue medications if deemed appropriate based on a patient’s change in acuity,” Dr. Kimmons said.
Methodist Le Bonheur Healthcare’s electronic health record (EHR) system prompts pharmacists to evaluate a patient’s drug regimen after they have been cleared to leave the ICU. Using prespecified criteria, a pharmacist can maintain a medication as is, modify the formulation or discontinue the medication.
Methodist Le Bonheur’s TOC program launched at the end of 2019 and included a new EHR alert informing providers that acid suppressants would be automatically discontinued upon ICU discharge if the medications had only been prescribed to prevent ICU ulcers and bleeding.
Dr. Kimmons and her colleagues compared patients treated before (n=150) and after (n=150) the TOC program commenced. After the program’s implementation, the investigators observed, the number of acid-suppressing medications continued at ICU discharge dropped significantly: Famotidine orders declined from 90% pre-implementation to 54% post-implementation (P=0.005); pantoprazole (Protonix, Pfizer) orders declined from 94.5% to 20% (P<0.001).
In addition to acid suppressants, ICU patients often receive antipsychotic medications to control delirium or agitation that may be continued even after the patient has been stabilized. These medications come with risks that range from mild inconveniences such as dry mouth to life-threatening conditions such as myocarditis (World Psychiatry 2018;17[3]:341-356).
The Methodist Le Bonheur TOC program significantly reduced the number of patients who received one such drug, quetiapine, after ICU discharge. (Quetiapine orders dropped from 90% pre-implementation to 28.6% post-implementation [P=0.005].) The program also enabled pharmacists to discontinue sedatives and IV infusions that were no longer needed.
Although there was some up-front work to code criteria for medication deescalation into the EHR and secure pharmacist authority to manage these medication orders, Dr. Kimmons noted, these tasks fit easily into the pharmacists’ workflow. “This program is efficient,” she said. “Every pharmacist has full authority within our scope of practice, so we can initiate medication changes any time of day. That’s what makes this program work.”
Tips for Deprescribing
“Every day, people are taking more medications than they need,” particularly older adults, observed Lisa McCarthy, PharmD, MSc, an associate professor at the University of Toronto’s Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine.
Dr. McCarthy cited one estimate that 150,000 older Americans could die prematurely this decade from polypharmacy. That’s not because they take only a few drugs concurrently; approximately 20% of older adults take 10 or more medications regularly. This is consistent with the situation in Canada, she said.
“I see deprescribing as part of prescribing, not as something separate. It is all part of the medication life cycle,” Dr. McCarthy said. “It’s about getting people the right agent in the right dose at the right time,” based on an ongoing analysis of whether the benefits of taking a drug outweigh the risks.
Dr. McCarthy is also a practicing pharmacist and a leader of deprescribing.org, a Canadian consortium founded in 2013 that develops evidence-based guidelines for when and how to deprescribe different types of medications safely.
Even if there’s strong evidence that a drug is no longer beneficial, a patient may be hesitant to discontinue it. Dr. McCarthy suggested developing an individualized tapering plan. Partnering with patients is crucial.
“To me it really starts with asking people, ‘What do you want for your life, and how do you feel your medications are serving you?’ That seems to be the way in to having a deprescribing conversation,” Dr. McCarthy said. For example, if a patient’s sleep medication appears to be causing frequent falls, starting the conversation this way may make them more receptive to changing it.
Software such as that used by Methodist Le Bonheur can help pharmacists identify potential risks for patients. “But it doesn’t help us have the conversation,” Dr. McCarthy said. Any plan to reduce or eliminate a drug should include monitoring and follow-up, she advised, to see whether the new approach is working.
“If someone feels better—or at least no worse—that’s awesome,” Dr. McCarthy said, referring to the effects of deprescribing.
The sources reported no relevant financial disclosures.
This article is from the April 2024 print issue.