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GP view: Deprescribing medicines could be a role for pharmacists

“Deprescribing forces us to confront the limits of what medicine can achieve”

Deprescribing medicines is an important aspect of palliative care that has scope for pharmacist involvement, says GP Toni Hazell

It’s a Monday lunchtime and I’m doing a ward round at a local care home when they ask me to see a new resident. Maud is 93 years old and has advanced dementia. She doesn’t talk and is bedbound, surviving mainly on oral nutritional supplements and the occasional bowl of soup. Her family were doing a sterling job of caring for her at home, but it all got too much for them.

As well as dementia, Maud has diabetes, hypertension and high cholesterol, though she has never had a cardiovascular problem that we know of. She is on three oral hypoglycaemic medicines, four antihypertensives and a statin, as well as aspirin and a proton-pump inhibitor. The care home staff are already finding it difficult to give her these medications, as they upset her, and would like permission to administer them covertly.

This is an all too common situation. In the days of evidence-based medicine, we were supposed to follow guidelines as much as possible. But guidelines are generally written with a single condition in mind and can cope poorly with a frail multimorbid patient.

For many years, I have used my judgment to think about stopping some medicines for patients like Maud, remembering that the National Institute for Health and Care Excellence (Nice) writes “guidelines not tramlines”. I try to consider what I would want to happen if this was my relative, or indeed me in the years to come.

The concept of deprescribing is something that needs training and judgment. It’s a potential role for pharmacists, for whom the principles of polypharmacy have long been part of their training.

Deprescribing is not easy, because it forces clinicians, patients and their families to confront the limits of what medicine can achieve, and raises mortality issues. In previous years, we’ve got much better at applying the principles of palliative care, long-established in the management of cancer, to other conditions such as dementia, heart failure and chronic obstructive pulmonary disease (COPD). Deprescribing is a part of this.

Maud’s life-expectancy is unlikely to be long – she would likely be on the palliative care register at her GP practice. It also appears that harm is being done by the fact that she is distressed at taking medicines. So is it really appropriate for her to be using a statin for primary prevention? We know that with these drugs we would have to treat over 100 patients for over three years to prevent one death.

There seems to be no indication for her aspirin prescription either, and this isn’t an uncommon situation. Aspirin for primary prevention of cardiovascular disease has gone in and out of fashion so many times in the last couple of decades that there are a number of patients who were started on it when their hypertension was diagnosed and have never stopped. If we stop the aspirin, she probably won’t need the proton-pump inhibitor.

What is her average blood glucose level over the last few months? There seems to be little point in striving for tight diabetes control. Nice would back this up, with their focus on personalised targets. They say that we should consider relaxing the target for patients who are unlikely to benefit from tight control due to a reduced life expectancy.

When we look at the number of deaths due to hypertension, we would need to treat over 100 people for many years to prevent one death. Is this really appropriate for Maud?

Back at the surgery, I phone Maud’s daughter and we have a long conversation. It was a very difficult decision for them to move her into a care home, and they fully understand the palliative nature of her dementia.

They appreciate me taking the time to ring and we decide to start by stopping her aspirin, statin, proton-pump inhibitor and one of her antihypertensive drugs. I will review things at the next ward round and we will try to keep her comfortable, rather than striving for meaningless targets.

This feels like proper general practice – weighing up the risks and benefits for an individual patient rather than blindly following guidelines. It is an area where there is huge scope for pharmacist involvement. Hopefully in years to come we will see a more sensible approach to the management of frail multimorbid patients, and when we all get there ourselves there won’t be quite such a burden of pills for us to take.

Toni Hazell is a GP based in a practice in London

9 Comments

Kevin Western, Community pharmacist

Off topic, I know, but what were your fellow GPs thinking when they dropped us in the brown stuff the other week? Did they care? Sitting happy behind their barrier of staff and phones?
Do they realise they broke the supply chain and came close to, if not in reality, breaking community Pharmacy?
I know most have no respect for us but they are in danger of getting all the stuff we normally filter dumped on their laps if we go belly up.

Stephanie Burns, Community pharmacist

I agree with you. I'm a relief pharmacist for a large multiple. The number of phone calls from patients saying that they need to order their prescriptions but they are in the shielded group. They have phoned their surgery to order their medication, only to be told they don't accept telephone requests - phone the pharmacy to do it.

In this pandemic crisis, surely they can accept telephone requests. They have access to their computer system so why can't they order as they talk to the patient?

We have to print off a repeat slip, tick the items required, get it to the surgery. If you are lucky the surgery will action it the next day, although at a few surgeries they quarantine the slips for 48hrs before touching them. Need I comment further? It isn't rocket science to see the most efficient system to follow!!!

SP Ph, Community pharmacist

I was under the impression that, this was the main reason for all those ""Clinical Pharmacists"" specially hired by the CPO Mr. R, with a special multi million pound package. If that is not helping and the community Pharmacists asked to do this Job, then just scrap the programme and fund the Community Pharmacy sector. We will do it, but not for free.

Greatly Pedantic and Highly Clueless, Senior Management

At lot of this excessive inappropriate prescribing is driven by NICE guidelines (Never Involves Clinical Evidence) and QoF (points make prizes). 

 

A huge proportion of community pharmacy's income still comes from script volume. Until this changes or there is some sort of fee attached, deprescribing isn't something finanicially community pharmacies can perform as regular service. I've certainly recommended patients be stopped on certain medications, but not for any financial gain (quite the opposite actually).

More than likely this will be something GP/PCN pharmacists will be doing.

ABC DEF, Primary care pharmacist

The main issue with deprescribing is the lack of guidelines and the liabilities that come with it. We may well know what drugs, in theory, that we can stop for a certain patient. But what if something happens after you stop it? For example what if a patient has a stroke and dies after you stop his edoxaban for AF because you think he is frail and DOAC is no longer considered essential? And with no clear guidance, there is nothing to back you up and you may find yourself trapped in lawsuits and FtP hearings of GPhC, risking your career and that's why no one wants to do it despite deprescribing has been talked about for so many years. 

Chloe Baxter, Primary care pharmacist

We spend so much time thinking of medicine optimisation as moving towards reducing HbA1C, reducing blood pressure etc.. and it's interesting to think as well that actually deprescribing can be of a massive benefit to a patient in the right circumstances. This would be a really interesting and rewarding area for pharmacists to move into.

SP Ph, Community pharmacist

I was under the impression that, this was the main reason for all those ""Clinical Pharmacists"" specially hired by the CPO Mr. R, with a special multi million pound package. If that is not helping and the community Pharmacists asked to do this Job, then just scrap the programme and fund the Community Pharmacy sector. We will do it, but not for free.

Benie I, Locum pharmacist

Is this something they would be paid for or just another weight to hang around their neck ?

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