[Translated article] Pharmaceutical recommendations for therapeutic appropriateness in patients with multiple sclerosis.

OBJECTIVE: To determine the prevalence of PIMDINAC criteria and to implement pharmacological interventions in a population with multiple sclerosis over 55 years of age. METHODS: Retrospective, observational, open-label study, including patients with multiple sclerosis aged 55 years and older during December 2022 and February 2023. The main variable determined was the percentage of compliance with the PIMDINAC criteria. RESULTS: Ninety-five patients were included, with the presence of PIMDINAC criteria detected in 67.4%. The most frequently detected criterion was non-adherence to concomitant treatment (84.4%), followed by drug-drug interactions (56.2%) and potentially inappropriate medication (25%). A total of 20 pharmaceutical interventions were performed in 17 patients (17.9%). Potentially inappropriate medication was responsible for 11 interventions, non-adherence for 7, and drug-drug interactions for 2. The 81.8% of interventions were accepted, resulting in the discontinuation of 15 inappropriately prescribed drugs. The prevalence of PIMDINAC criteria in this group of patients is high. The study revealed that PIMDINAC criteria were prevalent in 67.4% of the study population, with polypharmacy playing an important role, suggesting the potential for a multidisciplinary approach, through pharmaceutical interventions to address unnecessary or duplicate treatments.

Longitudinalidad en atención primaria y polifarmacia. Una revisión sistemática / Longitudinality in Primary Care and Polypharmacy. A Systematic Review

El objetivo de este trabajo es recopilar, evaluar e interpretar las evidencias disponibles sobre la relación existente entre el grado de longitudinalidad en atención primaria (AP) y la prevalencia de polifarmacia y sus problemas asociados. Siguiendo la declaración PRISMA realizamos una revisión sistemática de la literatura en las bases de datos PubMed y Scopus. El cribado por títulos y resúmenes, y la revisión de referencias realizados de forma independiente por 2 autores detectó 16 trabajos de potencial interés. Tras la revisión independiente de todos los originales, 4 fueron descartados por no satisfacer los criterios de inclusión. Los 12 trabajos seleccionados, 9 estudios de cohortes retrospectivos y 3 estudios transversales, estudiaban la relación de la longitudinalidad en AP, medida con diversos índices cuantitativos, con la prevalencia de polifarmacia y otros problemas terapéuticos asociados, como las prescripciones inadecuadas, las duplicidades o las interacciones medicamentosas. Todos mostraban una relación significativa, frecuentemente fuerte (RR>2 o<0,5), entre los indicadores de longitudinalidad y las diversas variables dependientes. Aunque nuestro conocimiento podría mejorar mediante estudios prospectivos que evaluaran directamente la longitudinalidad y su repercusión en los problemas por exceso de medicación, con las evidencias existentes, se puede afirmar que la protección y la promoción de la longitudinalidad en la AP es un elemento clave para el control de la polifarmacia y los problemas asociados (AU)

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems (AU)

[Longitudinality in Primary Care and Polypharmacy. A Systematic Review]. / Longitudinalidad en atención primaria y polifarmacia. Una revisión sistemática.

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.

Deprescripción en personas mayores: es el momento de pasar a la acción / Deprescription in old people: It's time to take action

El uso de fármacos conlleva innegables beneficios en las personas mayores, pero no está exento de efectos indeseables. La deprescripción es el proceso de revisión sistemática de la medicación con el objetivo de lograr la mejor relación riesgo-beneficio en base a la mejor evidencia disponible. Este proceso es especialmente importante en mayores polimedicados, sobretratados, frágiles, con enfermedades terminales y en el final de la vida.La deprescripción debe hacerse de forma escalonada, estableciendo un seguimiento estrecho por si aparecen problemas tras la retirada. En la toma de decisiones es muy importante contar con la opinión del paciente y de los cuidadores, valorando los objetivos del tratamiento según la situación clínica, funcional y social del enfermo.Existen múltiples herramientas para facilitar a los clínicos la tarea de seleccionar qué fármacos deprescribir (criterios Beers, STOPP-START…). Los grupos farmacológicos más susceptibles de intervención son: antihipertensivos, antidiabéticos, estatinas, benzodiacepinas, antidepresivos, anticolinérgicos, anticolinesterásicos y neurolépticos.(AU)

The use of drugs has undeniable benefits to the elderly, but it is not exempt from undesirable effects. Deprescription is the process of systematic medication review with the target of achieving the best risk-benefit ratio based on the best available evidence. This process is especially important for polymedicated elderly patients as well as those overtreated, frail, terminally ill and at the end of life.The deprescription must be done in stages, establishing a close follow-up in case problems appear after withdrawal. In the decision-making process, it is very important to consider the patient and caregivers opinion, assessing the objectives of the treatment according to the clinical, functional and social situation of the patient.There are multiple tools to make it easier for clinicians to select which drugs to deprescribe (Beers criteria, STOPP-START…). The most susceptible to intervention pharmacological groups are: antihypertensives, antidiabetics, statins, benzodiazepines, antidepressants, anticholinergics, anticholinesterase agents, and neuroleptics.(AU)

[Deprescription in old people: It's time to take action]. / Deprescripción en personas mayores: es el momento de pasar a la acción.

The use of drugs has undeniable benefits to the elderly, but it is not exempt from undesirable effects. Deprescription is the process of systematic medication review with the target of achieving the best risk-benefit ratio based on the best available evidence. This process is especially important for polymedicated elderly patients as well as those overtreated, frail, terminally ill and at the end of life. The deprescription must be done in stages, establishing a close follow-up in case problems appear after withdrawal. In the decision-making process, it is very important to consider the patient and caregivers opinion, assessing the objectives of the treatment according to the clinical, functional and social situation of the patient. There are multiple tools to make it easier for clinicians to select which drugs to deprescribe (Beers criteria, STOPP-START…). The most susceptible to intervention pharmacological groups are: antihypertensives, antidiabetics, statins, benzodiazepines, antidepressants, anticholinergics, anticholinesterase agents, and neuroleptics.

Deprescripción de medicamentos en pacientes adultos mayores: una revisión de la literatura / Deprescribing medications for elderly patients: a narrative review

Dado el envejecimiento poblacional que vive Chile, se hace cada vez más importante evaluar la seguridad y uso de medicamentos en adultos mayores. Una de las estrategias propuestas a nivel internacional es la deprescripción, que consiste en la disminución o eliminación de fármacos utilizados como tratamiento habitual. Para ello se diseñó esta revisión narrativa que pretendeofrecer un análisis de la literatura de la deprescripción de medicamentos en adultos mayores, con el fin de promover su práctica. Se realizó una búsqueda de artículos publicados entre los años 2003 al 2021, en bases de datos como Science Direct, MEDLINE, TripdataBase y Web of Science, seleccionando aquellos con mayor nivel de evidencia. Según la revisión la deprescripción, en general, se define como un proceso de retirada de la medicación inapropiada, bajo la supervisión de un profesional; siendo su principal causa la presencia de polifarmacia, y la prescripción de medicamentos potencialmente inapropiados. Los principales fármacos deprescritos con éxito (sin necesidad de ser reincorporados) corresponden a benzodiazepinas, antipsicóticos atípicos, corticoides, antidepresivos tricíclicos, estatinas e inhibidores de la bomba de protones. En conclusión: la deprescripción es un proceso poco estudiado, especialmente a nivel local; sin embargo, existe suficiente evidencia que avala la disminución los problemas de salud, en especial los referidos a la seguridad de la farmacoterapia en los adultos mayores.

It is becoming increasingly important to evaluate the safety and use of medications in older people in Chile, given the ageing of its population. Deprescription, which is defined as the reduction or elimination of drugs used by a given patient, is one of the strategies, proposed at the international level, to improve the safety of the pharmacotherapy. For this reason, this narrative review was designed, which aims to offer an analysis of the literature on medication deprescription in older adults, to promote its practice. For this, a search of articles published between 2003 and 2021 was performed in databases such as Science Direct, MEDLINE, TripdataBase, and Web of Science. The articles with the highest level of evidence were selected. It was found that deprescription, in general, is defined as a process of withdrawal of inappropriate drugs under the supervision of a healthcare professional; its leading cause is the presence of polypharmacy and the prescription of potentially problematic medications. The main medicines successfully deprescribed (without reincorporation) were benzodiazepines, atypical antipsychotics, corticosteroids, tricyclic antidepressants, statins, and proton pump inhibitors. In conclusion: deprescription is a poorly studied process, especially at the local level; however, there is sufficient evidence to support the reduction in health problems, especially those related to the safety of pharmacotherapy in the elderly.

Cronicidad y deprescripción colaborativa de los tratamientos con Benzodiacepinas / Chronicity and collaborative deprescribing of benzodiazepine treatments

JUSTIFICACIÓN: las Benzodiacepinas (BZD) son psicofármacos con indicaciones clínicas para ansiedad e insomnio, entre otras. Las guías clínicas son muy claras en relación a la duración de los tratamientos (4-12 semanas incluyendo el periodo de retirada), su uso prolongado es habitual y se asocia con tolerancia y dependencia, síndrome de abstinencia y factores de riesgo asociados. La deprescripción propone “el proceso de desmontaje de la prescripción de medicamentos por medio de su revisión, que concluye con la modificación de dosis, sustitución oelimin ación de unos fármacos o adición de otros”. Objetivos: Evaluar la duración de los planes de tratamientos con BZD en una Farmacia Comunitaria de Tenerife e identificar variables asociadas a la cronificación de los tratamientos con BZD como son la polimedicación y la revisión del plan de tratamiento y una posible derivación al médico para la deprescripción. Método: La cronicidad ha sido estudiada en 127 pacientes entrevistados en una Farmacia Comunitaria de Santa Cruz de Tenerife desde agosto 2020-febrero 2021 mediante preguntas incluidas en el CRD del estudio prospectivo observacional, descriptivo y transversal con código: DAA-CLO-2020-01, clasificado por la AEMPS y aprobado por el CEIm del Hospital Universitario de Canarias y el del Servicio de Ordenación Farmacéutica del Servicio Canario de la Salud.RESULTADOS: los pacientes estudiados presentan una media de 6,5 años en tratamiento con BZD si bien el rango es de 0,2-40 años. Al preguntar por el tipo de tratamiento en el 71,65 % de los pacientes es crónico, frente al 28,35 % que lo reciben de manera puntual. (AU)

Protocolo del estudioEstrategia de deprescripción deestatinas y ezetimiba en prevenciónprimaria en mayores de 75 años: análisis de los resultados en salud / Study protocol: A strategy for deprescribing statins and ezetimibe in primary prevention of cardiovascular disease in patients older than 75 years: health outcomes analysis

FUNDAMENTOS: l balance beneficio-riesgo de estatinas y ezetimiba como prevención primaria de la enfermedad cardiovascular (ECV) resulta controvertido en pacientes de edad avanzada, debido a las dudas sobre su efectividad y las certezas sobre efectos adversos. El objetivo de este estudio fue analizar los resultados en salud de una estrategia de deprescripción de estatinas y ezetimiba en prevención primaria de ECV en pacientes mayores de 75 años. MÉTODOS: Se realizó un estudio ambispectivo de cohortes para evaluar los resultados en salud obtenidos tras la implementación de una estrategia poblacional de deprescripción de estatinas y ezetimiba en pacientes con edad igual o mayor a 75 años que tomaban estos fármacos como prevención primaria de ECV. Para evitar posibles sesgos debidos a la asignación no aleatoria de los pacientes a los distintos grupos, se calculará un índice de propensión para cada paciente utilizando una regresión logística, en la que la variable de resultado será la deprescripción o no de estatinas o ezetimiba. Se analizará el tiempo hasta el ingreso hospitalario o la muerte por cualquier causa y otras variables relacionadas con resultados en salud. Se compararán los grupos con y sin deprescripción de estatina o ezetimiba mediante un análisis de supervivencia utilizando un modelo de riesgos proporcionales de Cox para estimar el hazard ratio. CONCLUSIONES: Se espera obtener información sobre los resultados en salud de la estrategia de deprescripción de estatinas y ezetimiba en prevención primaria en mayores de 75 años que informarán sobre la conveniencia de continuarla.(AU)

BACKGROUND: The benefit-risk balance of statins and ezetimibe as primary prevention of cardiovascular disease is controversial in elderly patients due to the doubts about their effectiveness and certainty about adverse effects. The aim of this paper was to analyze health outcomes of a statin and ezetimibe deprescription strategy in patients aged 75 or older treated with these drugs for primary prevention of cardiovascular disease. METHODS: An observational ambispective cohort study was made to evaluate health outcomes after the implementation of a strategy for deprescribing statins and ezetimibe in patients aged 75 or older who take these drugs for primary prevention of cardiovascular disease. To avoid the risk of bias due to non-random assignment of patients to different groups, a propensity score will be calculated for each patient using logistic regression. The outcome of interest will be the deprescription or not of statins or ezetimibe. Time to hospital admission or death from any cause and other variables related to health outcomes will be analysed. Groups with and without statin or ezetimibe deprescription will be compared by survival analysis using Cox regression to estimate the hazard ratio. CONCLUSIONS: It is expected to obtain health outcomes of the strategy of deprescribing statins and ezetimibe in primary prevention in patients aged 75 or older. They will provide information on the advisability of continuing the strategy.(AU)

Estrategia comunitaria municipal «yonomebenzo». Actividades y resultados en el período 2017-2020 / Municipal community strategy

Objetivo: Describir las actividades, el proceso y los resultados de la estrategia comunitaria Yonomebenzo desde 2017 a 2020. Metodología:Monitorización del proceso mediante evaluaciones periódicas para comprobar su impacto y desarrollar las actividades pendientes. Adaptación a la pandemia del coronavirus.Trabajar sobre la factibilidad del proceso a medio y largo plazo mediante el desarrollo de distintas estrategias. Intervención: Escuela del sueño: servicio centrado en personas ancianas ofreciendo alternativas saludables para facilitar el descanso nocturno.Oficina municipal del sueño: espacio abierto a población general sobre hábitos correctos de sueño.Mapeo de activos en salud (localizasalud): desarrollado en coordinación con Comisión de Salud Comunitaria municipal, enmarcado en la estrategia de Promoción de Salud y Prevención del Ministerio de Sanidad.Estrategia municipal de farmacias comunitarias: red voluntaria de 18 farmacias comunitarias. Factibilidad del proceso:A medio plazo: a través de los recursos económicos de ayudas del Ministerio de Sanidad y presupuestos municipales participativos.A largo plazo: municipalización de distintas actividades para financiarlas mediante presupuestos ordinarios. Intervenciones pendientes: Adaptación de actividades al contexto de la pandemia. Evaluación: Monitorización del consumo de benzodiacepinas (BZD) en dosis diaria definida/1.000 habitantes/año (DHD) y su adecuación. Aplicabilidad de la estrategia:Implicarla en contexto comunitario de atención centrada en el paciente, con profesionales de distintos ámbitos, asociaciones municipales y ciudadanía para mejorar el uso de BZD y desmedicalizar procesos cotidianos.Incorporar esta actividad comunitaria como programa municipal.Empoderar la población para controlar su propia salud. (AU)

Objective: Report the activities, process and results obtained from the Yonomebenzo community strategy from 2017 to 2020. Methodology: Follow up has been performed by means of periodic evaluations to verify the impact and develop new and pending activities.Adapting to the coronavirus pandemic.Medium and long-term feasibility has been improved by means of different strategies. Intervention. In addition to the activities performed up until 2016, new activities include:Sleeping school: focused on elderly people, offering healthy tips to improve night rest.Municipal Sleep Support Office: available for the entire population, emphasizes correct sleep hygiene.Health assets mapping (localizasalud): in collaboration with the municipal Community Health Commission, a Health Promotion and Prevention strategy carried out by the Ministry.Community-Pharmacies Municipal Strategy: implying 18 voluntary community pharmacies. Feasibility of the process:Medium term: by means of financial grants from the Ministry and participatory municipal budgets.Long term: municipalization of different activities to finance them by means of ordinary budgets. Interventions pending. Adaptation of activities against the backdrop of the pandemic. Evaluation. Monitoring of benzodiazepine (BZD) consumption as daily defined dose/1000 inhabitants/year (DDD) and its suitability. Application of the strategy:Implicate this into a community context for patient-focused care, with professionals from different areas, municipal associations and citizens to improve the use of BZD and stop treating ordinary processes as medical issues.Incorporate this community activity as a municipal programme.Empower the population to monitors its own health. (AU)

[Validation into Spanish of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire to assess patients' attitudes towards deprescribing. Research protocol]. / Validación al castellano del cuestionario revised Patients' Attitudes Towards Deprescribing (rPATD) para evaluar las actitudes de los pacientes hacia la deprescripción. Protocolo de investigación.

INTRODUCTION AND OBJECTIVE: Polypharmacy has become a priority public health problem in developed countries. In response to its approach, deprescription stands out. Its success will depend largely on the attitudes and beliefs of patients towards the number of drugs they are taking and their willingness to initiate a process of deprescription. To explore these factors, researchers have developed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire, originally in English. The objective of this study is the validation into Spanish of rPATD questionnaire, both older adults and caregivers versions. MATERIAL AND METHODS: A first qualitative validation phase and a second phase of analysis of its psychometric characteristics will be carried out through an observational descriptive study of validation of a measurement instrument. One hundred and twenty subjects (polymedicated older adults and caregivers) from three health centers will be selected by consecutive sampling. The questionnaire will be provided and clinical and sociodemographic data will be collected. Feasibility, reliability (through internal consistency and intraobserver reliability) and validity (apparent, construct and criterion) of the questionnaire will be evaluated. EXPECTED RESULTS: It is expected to obtain a questionnaire that will serve as a tool for the clinician to identify patients with a favorable predisposition to deprescription and that will allow to contribute the patient's perspective to this process. CONCLUSION: The use of the rPATD questionnaire, alone or integrated into other more complex interventions, may lead to an improvement in the quality of care for the polymedicated patients.

Herramientas y criterios para la de prescripción de medicación inapropiada en adultos mayores: una revisión de la literatura con implicaciones para la atención al paciente y la práctica clínica / Assessment tools and criteria for deprescribing inappropriate medication in older adults: A literature review with implications for patient care and clinical practice

Objetivo: Identificar las herramientas y los criterios para deprescribir medicación potencialmente inapropiada en adultos mayores. Métodos: Se realizó una búsqueda de literatura en MEDLINE (vía PubMed), EMBASE, LILACS, SCIELO, para recopilar las herramientas y criterios de evaluación para deprescribir medicamentos inapropiados en adultos mayores. Se incluyeron herramientas, algoritmos y enfoques, hasta marzo de 2020. Los términos se ajustaron para cada una de las bases de datos. Resultados: La estrategia de búsqueda produjo 3326 publicaciones potencialmente relevantes. Se evaluaron un total de 258 artículos y se incluyeron 69 en el análisis descriptivo. Estos se organizaron en dos categorías: criterios específicos (n =55) y algoritmos o enfoques para evaluar la medicación inapropiada (n =14). La mayoría de las herramientas y criterios fueron desarrollados basados en la evidencia. Conclusiones: Esta revisión proporciona una compilación de herramientas disponibles para identificar medicación potencialmente inapropiada en adultos mayores. Las herramientas y los criterios de evaluación sirven de apoyo a los profesionales de la salud para la toma decisiones en torno a los medicamentos usados en esta población. Además, estos resultados ilustran la complejidad de la farmacoterapia actual en los adultos mayores debido al número y tipo de medicamentos incluidos en las herramientas, como una alerta frente a su posible uso inapropiado. Los AINE y las benzodiazepinas son los fármacos más comunes en los criterios explícitos.(AU)

Objective: To identify tools and criteria for evaluating potentially inappropriate medication in older adults with implications in patient care and clinical practice. Methods: A literature search was conducted in MEDLINE (via PubMed), EMBASE, LILACS, SCIELO, to gather relevant data regarding assessment tools and criteria for deprescribing inappropriate medication in older adults. Assessment tools, algorithms, and approaches to identify potentially inappropriate medication were included from inception to March 2020. The terms were adjusted for each of the databases. Results: The search strategy produced 3326 potentially relevant publications. A total of 258 were evaluated. A total of 69 articles were included in the descriptive analysis. These were organized into two categories: specific criteria (n =55) and algorithm or frameworks for assessing medication (n =14). Most tools and criteria were developed using an evidence-based approach. Conclusions: This review provides a compile of available tools to identify potentially inappropriate medication in older people. Tools support health care professionals to make decisions around older adults and frail elderly medication. These results show the complexity of current pharmacotherapy in older people due to the number and type of drugs classes included in all of tools which is an alert of inappropriate use. NSAIDs and benzodiazepines are the most common drugs in the explicit criteria.(AU)

Deprescripción en el anciano polimedicado. Una mirada reflexiva en el contexto cubano / Deprescription in the polymedicated elderly. A reflexive look at the Cuban context

Introducción: El intervencionismo terapéutico excesivo propicia polifarmacia y errores de prescripción en ancianos. En Cuba, el anciano polimedicado es un problema recurrente; sin embargo, la información sobre deprescripción posee difusión limitada en el ámbito científico. Objetivo: Describir el conocimiento actual sobre deprescripción y la necesidad de una estrategia dirigida al anciano polimedicado en Cuba. Material y Métodos: Se realizó una revisión extendida desde 2003 hasta 2020, basado en la experticia de los autores. Los criterios de búsqueda, selección y el acceso a bases de datos y fuentes indexadas Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, Elsevier permitió citar 54 investigaciones (70 por ciento actualización) y redactar con metodología cualitativa, enfoque histórico-lógico, análisis-síntesis el documento final. Desarrollo: La deprescripción aparece desde 2003 para resolver la polifarmacia, es una herramienta de la prevención cuaternaria, implica desmontaje de medicación con varios matices. Su auge revolucionó diversas corrientes de trabajo en el mundo. Suficientes evidencias científicas de su necesidad y oportunidad para el mejor manejo farmacoterapéutico del anciano justifican un diseño e implementación atendiendo a las determinantes sociales de cada país. Se proponen elementos a la definición, se asevera la importancia de la farmacología geriátrica ante diseños de intervención. Conclusiones: La deprescripción es un proceso inherente de decisiones farmacoterapéuticas en ancianos atendidos en sistemas sanitarios de avanzada. Demuestra reducir mortalidad, medicamentos prescritos y prescripciones inapropiadas. El Programa Nacional de Medicamentos no dispone de directrices para su implementación, por lo que desarrollar una estrategia será un reto para la Salud Pública Cubana(AU)

Introduction: The excessive therapeutic interventionism promotes polypharmacy and prescription errors in the elderly. In Cuba, the polymedicated elderly is a recurrent problem; however, the information about prescription has a limited diffusion in the scientific field. Objective: To describe the current knowledge about deprescription and the need for a strategy aimed at addressing the problem of the polymedicated elderly in Cuba. Material and Methods: An extended review based on the authors' expertise was carried out from 2003 to 2020. The search and selection criteria and the access to databases and sources indexed in Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, and Elsevier allowed us to cite 54 research works (70 percent updated). The final document was written on the basis of qualitative research methodology and historical-logical and analysis-synthesis approaches. Development: The term "deprescription" appeared in 2003 to solve the problem of polypharmacy. It is a quaternary prevention tool that involves dismantling medication treatment with various nuances. Its rise revolutionized different work currents worldwide. Adequate scientific evidences of its need and opportunity for the best pharmacotherapeutic management in the elderly justify a design and implementation that takes into account the social determinants of each country. Some elements are suggested for the definition; the importance of geriatric pharmacology is affirmed in the face of intervention designs. Conclusions: Deprescription is an inherent process of pharmacotherapeutic decisions in elderly patients attended in advanced healthcare systems. It shows a reduction of mortality, prescription of drugs and inappropriate prescriptions. The National Drug Program does not have guidelines for its implementation; therefore, to develop a strategy will be a challenge for the Cuban Public Health(AU)

[What do primary care physicians think about deprescription?] / ¿Qué opinan los médicos de atención primaria sobre la deprescripción?

INTRODUCTION: To learn about the perceptions and attitudes of family doctors regarding deprescription. MATERIAL AND METHODS: This is a cross-sectional study conducted at the Organización Sanitaria Integrada Bidasoa, Osakidetza. In November 2018, sessions were held at health centres on deprescribing for family doctors, following which the PACPD-12 questionnaire was handed out, translated into Spanish and adapted. The responses to the questionnaire were collected, together with the socio-demographic variables. RESULTS: Forty-two of the 58 doctors who received the survey responded (72%). One hundred percent considered deprescription beneficial in the current scenario. The drug groups that they most frequently considered deprescribing were the benzodiazepines, bisphosphonates and proton pump inhibitors. The main reasons they gave for deprescribing were to reduce harm from adverse effects and that the medication was of minimal benefit in the patient's circumstances, and they indicated that specific training in deprescribing and pharmacist alerts in the clinical history would facilitate deprescription. Barriers highlighted were lack of time, prescribing by other professionals, or resistance on the part of the patient or their family. CONCLUSIONS: Knowing what doctors think about deprescribing and its barriers and facilitators are necessary to plan a strategy to facilitate the practice. Although all the respondents indicated that they consider deprescription beneficial, they found barriers in their daily practice to their being able to implement it.

Optimizando farmacoterapia mediante la deprescripción: reporte de caso / Optimizing pharmacotherapy through deprescription: Case report

RESUMEN La polifarmacia es el uso simultáneo o excesivo de varios medicamentos y ha presentado una tendencia al aumento durante los últimos años, al igual que los cuadros clínicos asociados a interacciones farmacológicas secundarias, llevando así a adicionar cada vez más medicamentos, esto genera el fenómeno de cascada en la prescripción. En este artículo se presenta un caso de una mujer de 34 años, identificado desde una plataforma transaccional de registro de medicamentos prescritos de una EPS, a quien se realizó seguimiento de su tratamiento farmacológico ambulatorio durante 7 meses, en los cuales presentó persistencia de polifarmacia. Se identificó en el caso posibles errores en medicación y posibles ajustes a la terapia que disminuirían el riesgo de interacciones o cascada de prescripción.

SUMMARY Polypharmacy is the simultaneous use or excess of dosage of medicines and it has shown a tendency to increase in recent years, as well as the clinical symptoms associated with secondary drug interactions, thus leading to the addition of more and more medications, generating the cascade phenomenon of prescription. We present a case of a 34-year-old woman, identified from a transactional platform of registration of prescribed drugs of an EPS, who was followed up on her outpatient pharmacological treatment for 7 months, in which she presented persistent polypharmacy. It was identified in the case possible errors in medication and possible adjustments to the therapy that would decrease the risk of interactions or prescription cascade.

Polifarmacia y deprescripción en personas mayores / Polypharmacy and deprescribing in older person

De acuerdo a las estimaciones mundiales, el año 2050, habrá más de 2000 millones de personas mayores (PM) de 60 años. En Chile, la situación no es distinta, el país está envejeciendo y esta situación nos expone a nuevos desafíos. Las PM, suelen presentar una mayor carga de enfermedad con el consiguiente aumento en la utilización de medicamentos para controlar su comorbilidad y multimorbilidad. Esta polifarmacia (uso de 5 o más medicamentos) trae consigo riesgos tales como el aumento de caídas, mayor fragilidad, aumento de los costos, entre otros. Para abordar estos riesgos en las PM, aparece el concepto de deprescripción como la práctica de retiro de medicamentos considerados inapropiados, supervisado por un profesional de la salud con el objetivo de gestionar la polifarmacia y mejorar los resultados clínicos. La deprescripción de medicamentos tales como las benzodiazepinas podrían mejorar la calidad del sueño y la calidad de vida, el retiro de analgésicos antinflamatorios no esteroidales y betabloqueadores disminuyen las caídas entre otros resultados. Esta práctica, debiese plantearse, por ejemplo, cuando los síntomas o síndromes coinciden con los efectos adversos a algunos de los medicamentos, cuando el paciente se encuentra en estadío avanzado de su enfermedad, con extrema fragilidad, con demencia avanzada o en cuidados de fin de vida. A pesar de que cada vez aparece más literatura que muestra la utilidad de deprescribir, queda aún pendiente expandir el conocimiento para generar evidencia de mejor calidad metodológica que oriente en qué escenarios se obtienen los mejores resultados para los pacientes.

According to global estimates, in the year 2050, there will be more than 2000 million older people (OP) of 60 years. In Chile, the situation is no different, the country is aging and this situation exposes us to new challenges. The OP, usually present a greater burden of disease resulting in an increase in the use of medications to control their comorbidity and multimorbility. This polypharmacy (the use of 5 or more drugs) it brings risks such as the increase in falls, greater fragility, increased costs, among others. To address these risks in the OP, the term deprescribing appears as the process of withdrawal of inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improve clinical outcomes. Deprescribing medications such as benzodiazepines could improve the quality of sleep and quality of life, the withdrawal of non-steroidal anti-inflammatory analgesics and beta-blockers decrease falls among other results. This practice should arise, for example, when the symptoms or syndromes coincide with adverse effects to some of the medicines, when the patient is in advanced stage of their illness, with extreme fragility, with advanced dementia or end-of-life care. Despite the fact that every time appears more literature that shows the usefulness of deprescribir, to expand the knowledge to generate evidence of better quality that show in which scenarios are obtained the best results for patients.

[Inappropriate drug use in palliative care: SPANISH version of the STOPP-Frail criteria (STOPP-Pal)]. / Uso potencialmente inapropiado de fármacos en cuidados paliativos: versión en castellano de los criterios STOPP-Frail (STOPP-Pal).

Multiple medication and inappropriate drug prescription are prevalent and challenging problems in older patients in end-of-life situations, and increases both preventable adverse events and health care costs. Recent literature recommends de-prescribing some drugs in patients with short life expectancy, when the aim of drug treatments is not prevention or cure, but symptom control. Recently, a list of explicit criteria (STOPP-Frail) intended to guide prescribing physicians in decision making on the use of drugs in older patients with terminal conditions. This article presents a Spanish version of such criteria, which have been named STOPP-Pal to avoid confusion with the current concept of frailty.

[Deprescribing to increase people health or when deprescribing could be the best pill]. / Deprescribiendo para mejorar la salud de las personas o cuando deprescribir puede ser la mejor medicina.

The increasing longevity of the population, the increase in morbidity and the consumption of medications have caused that polypharmacy is a priority health problem due to its consequences: increase of adverse effects, pharmacological interactions and favor the functional deterioration of the patient. The clinical situation of the patients changes over time and it is necessary to adjust the medication in each stage, assessing the fragility, the level of dependence and the functional deterioration. Deprescription is complex and requires an adequate clinical and pharmacological formation. In Primary Care lies the greater knowledge of the patient and their environment, and in a shared way with the patient and caregivers, it is necessary to assess which drugs to maintain and which ones to withdraw from a clinical, ethical and social perspective. There are tools to help deprescription that can be useful for Primary Care to facilitate this process and that are detailed in this article.

Antihypertensive overtreatment in people 80 years old and older. / Sobretratamiento antihipertensivo en mayores de 80 años.

BACKGROUND AND OBJECTIVE: To study the proportion of patients older than 80 years old with hypertension and pharmacological overtreatment. PATIENTS AND METHODS: Cross-sectional simulation study, including 281 patients older than 80 years old of primary prevention, randomly selected, with good control of hypertension (systolic blood pressure<150mmHg, diastolic blood pressure<90mmHg), treated with a maximum of 3 medications. Overtreatment was considered if at least one medication could be removed and good control persisted, calculating how the blood pressure would raise with Law's meta-analysis, which estimates blood pressure reductions by pre-treatment levels, number and dose of medications. RESULTS: The average age was 85.3 years (64.8% women). A percentage of 33.6 were taking one medication, 46.3% 2 and 22.1% 3, with the most prescribed being thiazides (69.4%), ACE inhibitors (51.3%), ARBs (23.4%), calcium antagonists (21%) and beta blockers (19.6%). Overtreatment was 90.7%, with 2 medications being able to be removed in 63.1% of cases and 3 in 43.1%. Polypharmacy (OR 2.47; 95% CI 1.07-5.69; P=.033) was associated with a greater likely removal of at least one medication. CONCLUSIONS: The proportion of patients with overtreatment is high. Changing good control criteria could contribute to a reasoned deprescription.

Luces y sombras de la deprescripción / Lights and shadows of deprescription

La deprescripción es un acto de prevención cuaternaria que pretende evitar, reducir y paliar el perjuicio provocado por intervenciones médicas. El objetivo de este estudio fue conocer los sentimientos, percepciones y actitudes de los pacientes ante la deprescripción de medicamentos y estudios, por parte de médicos de familia/generalistas de un Centro Médico de Atención Primaria. Se realizó un estudio cualitativo de abordaje fenomenológico en pacientes >18 años. Se realizaron 13 entrevistas, analizadas siguiendo la teoría fundamentada. Ante la deprescripción los pacientes deciden buscar una segunda opinión, validan el conocimiento médico según resultados clínicos, y cuestionan las indicaciones recibidas al salir de la consulta. Se enfrenta lo que el paciente trae consigo y demanda con lo que el médico indica. Cuando éste no lo favorece aparecen emociones como angustia, enojo, poniendo en juicio las intervenciones médicas. Se debilita la seguridad en su médico y aparece la desconfianza. Como conclusión, el paciente no adhiere a la deprescripción. Enfatizamos la necesidad de explorar la dolencia del paciente al momento de deprescribir, así como darle valor a su autonomía en la toma de decisiones.

Deprescription is a quaternary preventive action which aims at avoiding, reducing and alleviating the prejudice caused by medical interventions. The objective of this study was to know the patients' feelings, perceptions and attitudes towards deprescrition of medicine and studies of general practitioners/family doctors from a Primary Health Care Center. Qualitative study of phenomenological approach in patients >18 years was carried out. When facing deprescription patients decide to look for a second opinion, ratify medical knowledge according to clinical results, and question the medical indications when they leave the office. What the patient brings and demands what the doctor indicates is dealt with. When not in favor, feelings such as anguish, anger, arise and they judge medical intervention. Trust is weakened and distrust appears. As a conclusion, the patient does not adhere to deprescription. We emphasize the need to explore the patient's disease when deprescription occurs, as well as valuing autonomy in decision taking.

Prescripción prudente y deprescripción de fármacos como herramientas para la prevención cuaternaria / Prudent prescribing and deprescribing drugs as tools for quaternary prevention / Prescrição prudente e desprescrição de fármacos como ferramentas para a prevenção quaternária / Prudent prescribing and deprescribing drugs as tools for quaternary prevention

Las consecuencias de una medicación inadecuada son diversas y con gran repercusión a nivel clínico: desde efectos adversos e interacciones medicamentosas a fracturas por caídas y aumento de morbi-mortalidad. Para evitar o mejorar dichas consecuencias, así como para abordar sus causas y con la seguridad del paciente en mente, nace la deprescripción para conseguir una prescripción más segura, más prudente y más humana. La atención primaria se sitúa en un lugar privilegiado para hacer frente a este reto que debería formar parte de cualquier estrategia de prevención cuaternaria.

As consequências de uma medicação inadequada são diversas e com grande repercussão clínica: desde efeitos adversos e interações medicamentosas até fraturas por quedas e aumento da morbidade e mortalidade. Para se evitar ou amenizar essas consequências, bem como abordar as suas causas, levando-se em conta a segurança dos pacientes, surge a desprescrição para se obter uma prescrição mais segura, mais prudente e mais humana. A atenção primária está em uma posição privilegiada para enfrentar o desafio da desprescrição e esta deveria fazer parte de qualquer estratégia de prevenção quaternária.

The consequences of inappropriate medication are diverse and have great clinical impact: from adverse effects and medication interactions to fractures from falls and increased morbidity and mortality. To avoid or ameliorate such consequences, as well as to address its causes, bearing in mind patients' safety, deprescription has emerged as a safer, more prudent and humane practice. Primary care is in a privileged position to address this challenge of deprescription and it should be part of any strategy of quaternary prevention.