Validated medication deprescribing instruments for patients with palliative care needs: a systematic review / Instrumentos validados de desprescripción de medicamentos para los pacientes que reciben cuidados paliativos: una revisión sistemática

Objectives: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. Methods: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. Results: Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. Conclusions: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs)...(AU)

Objetivo: Los pacientes con enfermedades terminales son propensos a la polifarmacia innecesaria. Las herramientas de desprescripción pueden contribuir a minimizar los resultados negativos. Por lo tanto, los objetivos del estudio fueron identificar instrumentos validados para la desprescripción de medicamentos inapropiados en pacientes con necesidades de cuidados paliativos y evaluar el impacto en los resultados clínicos, humanísticos y económicos. Métodos: Se realizó una revisión sistemática en las bases de datos LILACS, PUBMED, EMBASE, COCHRANE y WEB OF SCIENCE (hasta mayo de 2021). Se realizó una búsqueda manual en las referencias de los artículos incluidos. La selección, elegibilidad, extracción y evaluación del riesgo de sesgo se llevaron a cabo por dos investigadores independientes. Se aceptó la inclusión de estudios observacionales y experimentales. Resultados: De los 5791 estudios recuperados, después de excluir duplicados (n = 1050), realizar la selección de títulos/resúmenes (n = 4741) y la lectura completa (n = 41), solo un estudio cumplió con los criterios de inclusión. En este estudio incluido, se realizó un ensayo controlado aleatorizado, que mostró un alto nivel de riesgo de sesgo en general. A los adultos de 75 años o más (n = 130) con esperanza de vida limitada y polifarmacia se les asignaron dos grupos [grupo de intervención (desprescripción) y grupo de control (atención habitual)]. Se realizó la desprescripción con la ayuda de la herramienta STOPPFrail. El número promedio de medicamentos inapropiados y los costos mensuales de los medicamentos fueron significativamente más bajos en el grupo de intervención. No se encontraron diferencias estadísticamente significativas en términos de presentaciones hospitalarias no programadas, caídas, fracturas, mortalidad y calidad de vida. Conclusiones: A pesar de la disponibilidad de varias herramientas para apoyar la deprescripción en pacientes con necesidades de cuidados paliativos...(AU)

Instrumentos validados de desprescripción de medicamentos para los pacientes que reciben cuidados paliativos: una revisión sistemática / Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

Objectives: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. Methods: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. Results: Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. Conclusions: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs)...(AU)

Objetivo: Los pacientes con enfermedades terminales son propensos a la polifarmacia innecesaria. Las herramientas de desprescripción pueden contribuir a minimizar los resultados negativos. Por lo tanto, los objetivos del estudio fueron identificar instrumentos validados para la desprescripción de medicamentos inapropiados en pacientes con necesidades de cuidados paliativos y evaluar el impacto en los resultados clínicos, humanísticos y económicos. Métodos: Se realizó una revisión sistemática en las bases de datos LILACS, PUBMED, EMBASE, COCHRANE y WEB OF SCIENCE (hasta mayo de 2021). Se realizó una búsqueda manual en las referencias de los artículos incluidos. La selección, elegibilidad, extracción y evaluación del riesgo de sesgo se llevaron a cabo por dos investigadores independientes. Se aceptó la inclusión de estudios observacionales y experimentales. Resultados: De los 5791 estudios recuperados, después de excluir duplicados (n = 1050), realizar la selección de títulos/resúmenes (n = 4741) y la lectura completa (n = 41), solo un estudio cumplió con los criterios de inclusión. En este estudio incluido, se realizó un ensayo controlado aleatorizado, que mostró un alto nivel de riesgo de sesgo en general. A los adultos de 75 años o más (n = 130) con esperanza de vida limitada y polifarmacia se les asignaron dos grupos [grupo de intervención (desprescripción) y grupo de control (atención habitual)]. Se realizó la desprescripción con la ayuda de la herramienta STOPPFrail. El número promedio de medicamentos inapropiados y los costos mensuales de los medicamentos fueron significativamente más bajos en el grupo de intervención. No se encontraron diferencias estadísticamente significativas en términos de presentaciones hospitalarias no programadas, caídas, fracturas, mortalidad y calidad de vida. Conclusiones: A pesar de la disponibilidad de varias herramientas para apoyar la deprescripción en pacientes con necesidades de cuidados paliativos...(AU)

Pharmaceutical recommendations for therapeutic appropriateness in multiple sclerosis patients. / Recomendaciones farmacéuticas de adecuación terapéutica en pacientes con esclerosis múltiple.

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 between 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.

Validated medication deprescribing instruments for patients with palliative care needs palliative care: A systematic review. / [Artículo traducido] Instrumentos validados de desprescripción de medicamentos para los pacientes con necesidades de cuidados paliativos: una revisión sistemática.

OBJECTIVES: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. METHODS: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by two independent researchers. Experimental and observational studies were eligible for inclusion. RESULTS: Out of the 5,791 studies retrieved, after excluding duplicates (n = 1,050), conducting title/abstract screening (n = 4,741), and full reading (n = 41), only one study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to two groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. CONCLUSIONS: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only one of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review.

OBJECTIVES: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. METHODS: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. RESULTS: Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. CONCLUSIONS: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Fracture risk after deprescription of bisphosphonates: Application of real-world data in primary care / Riesgo de fractura después de la desprescripción de bifosfonatos: aplicación de real-world data en atención primaria

Purpose: To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture. Design: Retrospective, longitudinal and population-based cohort study. Setting: Barcelona City Primary Care. Catalan Health Institute. Participants: All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years. Intervention: Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up. Main measurements: The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models. Results: We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87–1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47–0.88) and total fractures (HR 0.77, 95% CI 0.64–0.92). Conclusion: Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures.(AU)

Objetivo: Comparar el efecto de la desprescripción de bifosfonatos sobre el riesgo de fractura en mujeres posmenopáusicas con alto y bajo riesgo de fractura. Diseño: Estudio de cohortes retrospectivo, longitudinal y de base poblacional. Emplazamiento: Atención primaria Barcelona. Institut Català de la Salut. Participantes: Se incluyeron todas las mujeres atendidas por los equipos de atención primaria que a enero de 2014 habían recibido tratamiento con bifosfonatos durante al menos cinco años. Intervención: Se clasificó a las pacientes según su riesgo de nuevas fracturas, definido como presencia de antecedentes de fractura osteoporótica y/o tratamiento con un inhibidor de la aromatasa, y se analizó la continuidad o desprescripción del tratamiento con bifosfonatos a lo largo de cinco años de seguimiento. Mediciones principales: La incidencia acumulada de fracturas y la densidad de incidencia se calcularon y analizaron mediante regresión logística y modelos de Cox. Resultados: Se incluyeron 3.680 mujeres. No hubo diferencias significativas en el riesgo de fractura en mujeres de alto riesgo que desprescribieron el bisfosfonato comparado con aquellas que continuaron (hazard ratio [HR] 1,17, intervalo de confianza [IC] de 95% 0,87-1,58 para fracturas osteoporóticas totales). Sin embargo, los que discontinuaron con bajo riesgo tuvieron una menor incidencia de fractura que los que continuaron. Esta diferencia fue significativa para fracturas vertebrales (HR 0,64, IC 95% 0,47-0,88) y fracturas totales (HR 0,77, IC 95% 0,64-0,92). Conclusiones: Nuestros resultados sugieren que la desprescripción de bifosfonatos en mujeres que ya han recibido cinco años de tratamiento no aumenta el riesgo de fractura. En mujeres de bajo riesgo, la continuación de este tratamiento podría incluso favorecer la aparición de nuevas fracturas osteoporóticas.(AU)

Atención farmacéutica al paciente ingresado en una unidad multidisciplinar de paciente crónico complejo / Pharmaceutical care for the patients admitted to a multidisciplinary complex chronic patient unit

Objetivo: evaluar la contribución del farmacéutico mediante el análisis de la prescripción potencialmente inapropiada y la conciliación del tratamiento domiciliario en la unidad de pacientes crónicos complejos de un hospital terciario. Métodos: estudio observacional, prospectivo y multidisciplinar de los pacientes de la unidad de pacientes crónicos complejos de un hospital durante febrero de 2019 - junio de 2020. El equipo multidisciplinar del crónico complejo elaboró un checklist con una selección de fármacos no recomendados basado en los criterios STOPP/START, Beers y PRISCUS y fármacos susceptibles de desprescripción según los criterios LESS-CHRON. El farmacéutico aplicaba el checklist diariamente en los pacientes que ingresaban en la unidad, además de realizar la conciliación del tratamiento domiciliario revisando el tratamiento prescrito con el detallado en la receta electrónica domiciliaria. Por eso, se recogieron las siguientes variables: edad, sexo y número de fármacos al ingreso como variables independientes, y variables dependientes: número de fármacos al alta, tipo de prescripción potencialmente inapropiada, motivos de conciliación, fármacos implicados y grado de aceptación de la recomendación por parte del médico prescriptor para evaluar la contribución farmacéutica. El análisis estadístico se realizó con IBM® SPSS® Statistics22. Resultados : se revisaron 621 pacientes con una mediana de edad de 84 años (56,4% mujeres), y se intervino en 218 (35,1%). La mediana del número de fármacos fue de 11 (2-26) al ingreso y de 10 (0-25) al alta. Se realizaron 373 intervenciones: 235 por conciliación de la medicación (78,3% aceptadas), 71 por medicamentos no recomendados (57,7% aceptadas), 42 por desprescripción (61,9% aceptadas) y 25 por otros motivos. ... (AU)

Objective: To assess the pharmacist’s contributions by analysing potentially inappropriate prescription and home treatment reconciliation in the complex chronic patient unit of a tertiary hospital.MethodObservational, prospective, multidisciplinary study of patients in the complex chronic patient unit of a hospital during February 2019 - June 2020. Multidisciplinary team of the complex chronic developed a checklist with a selection of non-recommended drugs based on STOPP/START, Beers and PRISCUS criteria, and drugs susceptible to deprescription according to LESS-CHRON criteria. The pharmacist applied the checklist daily in patients admitted to the unit, in addition to reconciling home treatment by reviewing the prescribed treatment with that detailed in the electronic home prescription. Therefore, the following variables were collected: age, sex and number of drugs on admission as independent variables, and dependent variables: number of drugs at discharge, type of potentially inappropriate prescription, reasons for reconciliation, drugs involved and degree of acceptance of the recommendation by the prescribing physician to assess the pharmaceutical contribution. The statistical analysis was performed with IBM® SPSS® Statistics22.Results: We reviewed 621 patients with a median age of 84 years (56.4% women), and intervention was performed in 218 (35.1%). The median number of drugs was 11 (2-26) at admission and 10 (0-25) at discharge 373 interventions were performed: 235 for medication reconciliation (78.3% accepted), 71 for non-recommended drugs (57.7% accepted), 42 for deprescription (61.9% accepted) and 25 for other reasons. Statistically significant differences were observed between the number of drugs at discharge and at admission in both intervention patients (n = 218) and complex chronic patients (n = 114) (p < 0.001 in both cases). ...(AU)

Fracture risk after deprescription of bisphosphonates: Application of real-world data in primary care.

PURPOSE: To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture. DESIGN: Retrospective, longitudinal and population-based cohort study. SETTING: Barcelona City Primary Care. Catalan Health Institute. PARTICIPANTS: All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years. INTERVENTION: Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up. MAIN MEASUREMENTS: The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models. RESULTS: We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87-1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47-0.88) and total fractures (HR 0.77, 95% CI 0.64-0.92). CONCLUSION: Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures.

Pharmaceutical care for the patients admitted to a multidisciplinary complex chronic patient unit. / [Artículo traducido] Atención farmacéutica al paciente ingresado en una unidad multidisciplinar de paciente crónico complejo.

OBJECTIVE: To assess the pharmacist's contributions by analysing potentially inappropriate prescription and home treatment reconciliation in the complex chronic patient unit of a tertiary hospital. METHOD: Observational, prospective, multidisciplinary study of patients in the complex chronic patient unit of a hospital during February 2019 - June 2020. Multidisciplinary team of the complex chronic developed a checklist with a selection of non-recommended drugs based on STOPP/START, Beers and PRISCUS criteria, and drugs susceptible to deprescription according to LESS-CHRON criteria. The pharmacist applied the checklist daily in patients admitted to the unit, in addition to reconciling home treatment by reviewing the prescribed treatment with that detailed in the electronic home prescription. Therefore, the following variables were collected: age, sex and number of drugs on admission as independent variables, and dependent variables: number of drugs at discharge, type of potentially inappropriate prescription, reasons for reconciliation, drugs involved and degree of acceptance of the recommendation by the prescribing physician to assess the pharmaceutical contribution. The statistical analysis was performed with IBM® SPSS® Statistics22. RESULTS: We reviewed 621 patients with a median age of 84 years (56.4% women), and intervention was performed in 218 (35.1%). The median number of drugs was 11 (2-26) at admission and 10 (0-25) at discharge 373 interventions were performed: 235 for medication reconciliation (78.3% accepted), 71 for non-recommended drugs (57.7% accepted), 42 for deprescription (61.9% accepted) and 25 for other reasons. Statistically significant differences were observed between the number of drugs at discharge and at admission in both intervention patients (n = 218) and complex chronic patients (n = 114) (p < 0.001 in both cases). Moreover, statistically significant differences were observed in the number of drugs at admission between patients included in the complex chronic programme and those not included (p = 0.001), and in the number of drugs at discharge (p = 0.006). CONCLUSIONS: The integration of the pharmacist in the multidisciplinary team of the complex chronic patient unit improves patient safety and quality of care. The selected criteria were useful for detecting inappropriate drugs in this population and favoured deprescription.

Pharmaceutical care for the patients admitted to a multidisciplinary complex chronic patient unit.

OBJECTIVE: To assess the pharmacist's contributions by analyzing potentially inappropriate prescription and home treatment reconciliation in the complex chronic patient unit of a tertiary hospital. METHOD: Observational, prospective, multidisciplinary study of patients in the complex chronic patient unit of a hospital during February 2019-June 2020. Multidisciplinary team of the complex chronic developed a checklist with a selection of non-recommended drugs based on STOPP/START, Beers and Priscus criteria, and drugs susceptible to deprescription according to LESS-CHRON criteria. The pharmacist applied the checklist daily in patients admitted to the unit, in addition to reconciling home treatment by reviewing the prescribed treatment with that detailed in the electronic home prescription. Therefore, the following variables were collected: age, sex and number of drugs on admission as independent variables, and dependent variables: number of drugs at discharge, type of potentially inappropriate prescription, reasons for reconciliation, drugs involved and degree of acceptance of the recommendation by the prescribing physician to assess the pharmaceutical contribution. The statistical analysis was performed with IBM® SPSS® Statistics22. RESULTS: We reviewed 621 patients with a median age of 84 years (56.4% women), and intervention was performed in 218 (35.1%). The median number of drugs was 11 (2-26) at admission and 10 (0-25) at discharge. 373 interventions were performed: 235 for medication reconciliation (78.3% accepted), 71 for non-recommended drugs (57.7% accepted), 42 for deprescription (61.9% accepted) and 25 for other reasons. Statistically significant differences were observed between the number of drugs at discharge and at admission in both intervention patients (n = 218) and complex chronic patients (n = 114) (p < 0.001 in both cases). Moreover, statistically significant differences were observed in the number of drugs at admission between patients included in the complex chronic programme and those not included (p = 0.001), and in the number of drugs at discharge (p = 0.006). CONCLUSIONS: The integration of the pharmacist in the multidisciplinary team of the complex chronic patient unit improves patient safety and quality of care. The selected criteria were useful for detecting inappropriate drugs in this population and favored deprescription.

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. Methods A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. Results Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. Conclusions Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Adaptación transcultural y validación al español del cuestionario de desprescripción en el paciente de edad avanzada / Cross-cultural adaptation and validation into Spanish of the deprescription questionnaire in the elderly patient

Antecedentes y objetivo: En 2017 se desarrolló un cuestionario en italiano que tenía como objetivo determinar las percepciones de los clínicos ante la desprescripción en población de edad avanzada.El objetivo fue traducir y adaptar transculturalmente al español este cuestionario de desprescripción.MétodosTraducción directa y retrotraducción, seguidas de una síntesis y adaptación por un tercer traductor. Desarrollo de un panel de expertos para evaluar la adecuación de la traducción, comprensibilidad de la pregunta traducida y utilidad de cada cuestión. Se realizó un análisis de comprensibilidad a médicos familiarizados con la desprescripción.ResultadosSe obtuvo la versión española del cuestionario, donde el grado de dificultad medio en la traducción directa e inversa fue baja/moderada. En la primera fase del panel de expertos 4 preguntas tuvieron apartados considerados «indeterminados» y una fue «dudosa». Tras la segunda fase, todas las cuestiones fueron «adecuadas» a excepción de una.ConclusionesSe trata de la primera adaptación transcultural al español de este cuestionario, lo que permitirá disponer de una herramienta para valorar la percepción de los clínicos y establecer mejoras en la realización de esta práctica. (AU)

Background and objective: In 2017, a questionnaire was developed in Italian with the aim of determining clinicians’ perceptions of deprescription in the elderly population.The objective was to translate and cross-culturally adapt this deprescription questionnaire to Spanish.MethodsForward and blind-back translations, followed by a synthesis and adaptation by a third translator. Development of an expert panel to evaluate the adequacy of the translation, the understandability of the translated question and the usefulness of each question. A comprehensibility analysis was carried out on physicians familiar with deprescription.ResultsThe Spanish version of the questionnaire was obtained, where the average degree of difficulty in the direct and the back-translation was low/moderate. In the first phase of the panel of experts, 4 questions had sections considered “indeterminate” and one question was “doubtful”. After the second phase, all the questions were considered “adequate” except for one.ConclusionsThis is the first cross-cultural adaptation to Spanish of this questionnaire, which will provide a tool to assess clinicians’ perception of this practice and establish improvements to carry out this activity. (AU)

Protocolo de validación de la herramientade desprescripción LESS-CHRON en pacientespluripatológicos. Proyecto LESS-CHRON-VALIDATION / Validation protocol of the LESS-CHRON deprescription tool in multimorbidity patients. LESS-CHRON-VALIDATION Project

Objetivo: La desprescripción se considera una de las principales estrategias disponibles para el abordaje del plan terapéutico individualizado enpacientes pluripatológicos o crónicos complejos. Sin embargo, a pesar deser una práctica ya instaurada desde hace algunos años, se reclama lanecesidad de estudios que avalen la obtención de buenos resultados ensalud, además de herramientas que ayuden a su desarrollo en la prácticaclínica habitual. El objetivo de este proyecto es analizar el impacto en ladisminución de la farmacoterapia mediante la desprescripción de fármacos,aplicando la herramienta LESS-CHRON, en una población de pacientes deedad avanzada, polimedicada y con múltiples patologías.Método: Estudio cuasiexperimental, pre-post, multicéntrico. Las variables aanalizar se dividirán en dos grandes grupos: referidas a la esfera farmacológica y referidas a resultados en salud. Se recogerán en el momento basal,a los 3 y a los 6-12 meses. Se realizará una primera fase de screening paralocalizar a los pacientes candidatos, que permitirá obtener la informaciónrelativa a las oportunidades de desprescripción identificadas. La segundaconstituirá la fase de intervención, en la que se aplicará la herramientaLESS-CHRON y se llevará a cabo la desprescripción real de los fármacos.(AU)

Objective: Deprescribing is considered one of the main strategies available for preparing an individualized therapeutic plan in patients withmultiple pathologies or complex chronic conditions. However, despite thepractice has been in place for some years, there is a need for studies thatsupport the achievement of satisfactory health outcomes, as well as toolsthat help implement deprescribing in routine clinical practice. The objective of this project is to analyze the impact of reducing polypharmacy,through the LESS-CHRON deprescribing tool, on a population of elderlypolymedicated patients with multiple conditions.Method: This will be a quasi-experimental, pre-and-post interventionmulticenter cohort study. The variables to be analyzed will be dividedinto two large groups: those related to pharmacology and those related to health outcomes. They will be collected at baseline, at 3 and at6-12 months. A first screening phase will be carried out to recruit candidate patients and obtain information about the identified deprescribingopportunities. The second phase will constitute the intervention phase,where the LESS-CHRON tool will be applied and the actual deprescribingof the drugs will be carried out. (AU)

Polifarmacia en paciente VIH mayor de 50 años / Polypharmacy in HIV patient older than 50 years

Introducción: Los pacientes con virus de la inmunodeficiencia humana (VIH) han aumentado su esperanza de vida, convirtiéndose así el VIH en una enfermedad crónica gracias al tratamiento antirretroviral (TAR), que aunque no sea capaz de erradicar el virus, mantiene la carga viral suprimida e incrementa el número de linfocitos-CD4. Consecuentemente, ha aumentado el número de comorbilidades en esta población, y con ello su polifarmacia.Objetivo: Analizar la medicación TAR y no-TAR de pacientes VIH ≥50 años, determinando el grado de polifarmacia y las interacciones potenciales relevantes.Material y métodos: Estudio retrospectivo, observacional, unicéntrico, analítico, transversal. Se incluyeron los pacientes VIH ≥50 años que acudieron al Servicio de Farmacia para recogida de medicación: 7-enero al 3-febrero, 2019. Se recogieron las variables: edad, sexo, estratificación según la Estrategia de Atención Farmacéutica al Paciente Crónico de Jimena®, TAR y medicación no-TAR.Resultados: Se incluyeron un total de 114 pacientes ≥50 años, el 96,97% tenía medicación concomitante, destacando fármacos para el sistema cardiovascular y para el sistema nervioso central (SNC). Se identificaron 99 interacciones potenciales significativas TAR/no-TAR en 66 pacientes, ocurriendo principalmente con los fármacos para el SNC. Los TAR principalmente implicados fueron los inhibidores de la transcriptasa inversa no análogos de nucleósidos, inhibidores de la proteasa potenciados e inhibidores de la integrasa potenciados (INI/p).Conclusiones: El médico prescriptor del TAR debe tener en cuenta la polifarmacia de estos pacientes, intentar desprescribir medicación innecesaria en la medida de lo posible y buscar alternativas con menor repercusión, como puede ser el uso de INI en el contexto del TAR. (AU)

Background: Human immunodeficiency virus (HIV) in patients have increased their life expectancy, making HIV a chronic illness, thanks to the antiretroviral treatment (ART), which, despite the fact it is not able to eradicate the HIV, it keeps the viral load supressed and increases the number of CD4 lymphocytes. Consequently, the number of comorbidities in this population has increased so, its polypharmacy as well.Objective: To analyze the ART and non-ART medication of HIV patients ≥50 years old, determining the degree of polypharmacy and relevant interactions.Material and methods: Observational retrospective study, mono-site, analytical and transversal. HIV patients ≥50 years old who went to the Pharmacy Service for collecting medication from January 7th untill February 3rd, 2019. The following variables were selected: age, sex, stratification according to the Strategy of Pharmaceutical Care to the Patient Chronic of Jimena®, ART and non-ART medication.Results: A total of 114 patients ≥50 years old were included, 96.97% had concomitant medication, highlighting drugs for the cardiovascular system and for the central nervous system. 99 significant interactions ART/non-ART were identified in 66 patients, occurring mainly with drugs for the central nervous system. The ARTs mainly involved were the non-nucleoside reverse transcriptase inhibitors, boosted protease inhibitors and boosted integrase inhibitors (INI).Conclusions: Prescribe physicians of ARTs must take into account to the polypharmacy of the patients, try to deprescribe unnecessary medication as much as possible and find alternatives with less repercussion, such as the use of Inhibitors of the Integrase, in the context of ART. (AU)

[Cross-cultural adaptation and validation into Spanish of the deprescription questionnaire in the elderly patient]. / Adaptación transcultural y validación al español del cuestionario de desprescripción en el paciente de edad avanzada.

BACKGROUND AND OBJECTIVE: In 2017, a questionnaire was developed in Italian with the aim of determining clinicians' perceptions of deprescription in the elderly population. The objective was to translate and cross-culturally adapt this deprescription questionnaire to Spanish. METHODS: Forward and blind-back translations, followed by a synthesis and adaptation by a third translator. Development of an expert panel to evaluate the adequacy of the translation, the understandability of the translated question and the usefulness of each question. A comprehensibility analysis was carried out on physicians familiar with deprescription. RESULTS: The Spanish version of the questionnaire was obtained, where the average degree of difficulty in the direct and the back-translation was low/moderate. In the first phase of the panel of experts, 4 questions had sections considered "indeterminate" and one question was "doubtful". After the second phase, all the questions were considered "adequate" except for one. CONCLUSIONS: This is the first cross-cultural adaptation to Spanish of this questionnaire, which will provide a tool to assess clinicians' perception of this practice and establish improvements to carry out this activity.

¿Conlleva la desprescripción de condroprotectores en pacientes con artrosis un incremento del consumo de analgésicos? Estudio observacional retrospectivo / Does the deprescription of chondroprotectors in patients with osteoarthritis lead to an increase in the consumption of analgesics? Observational retrospective study

Objetivo: El objetivo del estudio es evaluar si la desprescripción de medicamentos considerados de bajo valor intrínseco como los condroprotectores o SYSADOA, conlleva un empeoramiento sintomáti-co de la artrosis, incrementándose el consumo de analgésicos.Material y métodos: Siguiendo la práctica clínica habitual se retiró el tratamiento con SYSADOA a pa-cientes de un Centro de Atención Primaria (pobla-ción asignada: 34.382 habitantes, 17% mayores de 65 años) en base a la evidencia científica publicada y a la recomendación de la administración sanitaria de reducir los tratamientos con medicamentos de bajo valor intrínseco. Mediante un estudio obser-vacional post-intervención se analizaron diferen-cias de consumo de analgésicos y AINEs entre un periodo anterior a la retirada y el mismo periodo post-retirada.Resultados: Se analizaron 354 pacientes (68,4% mujeres, media de edad 66,2 años). No se encon-traron diferencias estadísticamente significativas en el consumo de analgesia total en el periodo de 6 meses post-retirada (media de 3,97 envases) com-parado con el periodo de 6 meses previo (media de 4,04 envases). Al estratificar por código ATC, edad y género, únicamente se encontraron diferencias en el consumo de otros analgésicos y antipiréticos teniendo en cuenta el sexo.Conclusión: Se concluye que, considerar con el paciente la desprescripción de SYSADOA a criterio del médico, es seguro y no conlleva un aumento del consumo de analgésicos (otros analgésicos y anti-piréticos, AINE, opioides menores, opioides mayo-res) sugiriendo que no implica un empeoramiento de la enfermedad artrósica. La desprescripción de SYSADOA, además, puede contribuir a reducir la po-limedicación sin alterar la situación clínica y evitar posibles riesgos de efectos adversos o interaccio-nes potenciales (AU)

Objective: The objective of this study is to assess if the deprescription of medications that are consid-ered low intrinsic value medications such as the chondroprotectors or SYSADOA entails a symptom-atic worsening of the arthrosis and consequently an increase of the consumption of analgesics.Material and Methods: Following the usual clinical practise, the SYSADOA treatment was withdrawn to the patients from a Primary Health Care Centre (assigned population: 34,382 inhabitants, 17% up to 65 years old) according to the published scientific proof and the recommendation of the health ad-ministration consisting of reducing the treatments with low intrinsic value medications. Differences in consumption of analgesics and AINEs between a previous period before the withdrawn and the same period post-withdrawn were studied through an observational post-intervention study.Results: 354 patients were analysed (68,4% wom-en, average age 66,2 years). There were not found significant differences from a statistical point of view in the total consumption of analgesia in the 6 months period post-withdrawn (average of 3,97 packagings) compared to the previous period of 6 months (average of 4,04 packagings). When stratifying by ATC code, age and gender, there were only found differences in the consumption of other analgesics and antipyretics taking into account the sex.Conclusion: It is concluded that considering togeth-er with the patient the deprescription of SYSADOA according to doctor’s criteria is safe and does not involve an increase of analgesics consumption (other analgesics, antipyretics, AINEs, major and minor opiods) suggesting that it does not suppose a worsening of the arthrosis disease. Besides, the deprescription of SYSADOA may contribute to re-duce polymedication without disrupting the clinical situation and avoid possible risks of adverse effects or potential interactions

Riesgo-beneficio de la retirada de estatinas en cuidados paliativos: revisión sistemática de la literatura / Risks and benefits of statin deprescription in palliative care: a systemic review of the literature

Introducción: El uso de estatinas en pacientes con enfermedad terminal avanzada no queda claro; el tiempo para obtener un beneficio es superior a la supervivencia, a los efectos adversos e interacciones farmacológicas. El objetivo es buscar evidencia científica del riesgo-beneficio en la retirada de estatinas en pacientes con enfermedad terminal avanzada. Metodología: Revisión sistemática bibliográfica de artículos en inglés y español publicados entre 2013 y 2018. Bases de datos: Pubmed, Scopus, Cochrane, Google académico, Cercatot de la web de la Biblioteca de la Universidad de Lleida. Parámetros analizados: tipo de estudio, tamaño de muestra, esperanza de vida, resultados más significativos y posibles limitaciones. Selección de artículos mediante la lectura del título y/o resumen, posterior lectura completa del texto. Resultados: Encontramos 224 artículos, 13 cumplen criterios. Los beneficios de estatinas en prevención primaria se observan entre 6 meses y 3 años. Presentan mayor susceptibilidad a efectos adversos personas con edad avanzada, caquexia o fragilidad. Los efectos adversos principales fueron: gastrointestinales (8 %), dolores musculoesqueléticos (mayor al 7 %). Las miopatías fueron más frecuentes en mujeres y en personas con niveles de vitamina D bajos. Las interacciones principales fueron con amlodipino, fluconazol o ketoconazol, warfarina, verapamilo o eritromicina. Mejor calidad de vida percibida en el grupo que descontinúa estatinas. La desprescripción ocurre habitualmente horas o días antes del fallecimiento. Conclusiones: La intervención paliativa precoz al retirar las estatinas cuando estas ya no ofrezcan un beneficio podría ofrecer beneficios como evitar efectos adversos e interacciones y mejorar la calidad de vida. Sería útil la estandarización de criterios. (AU)

Introduction: The use of statins in patients with advanced terminal disease is unclear: the time needed to obtain benefits is greater than survival, and adverse effects as well as pharmacological interactions may occur. The objective was to find scientific information regarding the risks and benefits of statin deprescription in patients with limited prognosis. Methodology: A systematic review of the literature in English and Spanish published between 2013 through 2018. Search: PubMed, Scopus, Cochrane, Google Scholar, Cercatot (University of Lleida web services). Data analyzed: type of study, population size, life expectancy, notable results, and possible limitations. The selection of articles was done by reading the title and/or abstract; the whole paper was read subsequently. Results: We found 224 articles, 13 met the criteria. The benefits of statins in primary prevention are observed between 6 months and 3 years. An increased susceptibility to side effects was seen in the elderly, cachectic, or frail patients. Major side effects included: gastrointestinal events (8%), and musculoskeletal pain (above 7%). Myopathies were more common in women and in people with low vitamin D levels. Most common interactions occurred with amlodipine, fluconazole or ketoconazole, warfarin, verapamil or erythromycin. A better quality of life was perceived in the group that discontinued statins. Deprescription usually occurs hours or days before death. Conclusions: In early palliative intervention the withdrawal of statins when they no longer offer any benefits could benefit our patients by avoiding adverse effects and interactions, thus improving quality of life. A standardization of criteria would be useful. (AU)

[Benzoletter: minimal intervention for deprescribing benzodiazepines in patients with insomnia]. / Benzocarta: intervención mínima para la desprescripción de benzodiacepinas en pacientes con insomnio.

OBJECTIVE: To determine whether a letter-based intervention to patients taking benzodiazepines reduces their consumption. METHOD: A before-after study without control group performed in primary care in May 2016. 1582 patients who took a single daily dose of benzodiazepines as hypnotic for more than 3 months were sent a personalized letter from their family doctor. The letter contained information about the risks of long-term benzodiazepine consumption and the recommendation to discontinue them with a gradual drop protocol (Benzoletter). The percentage of patients who stopped or decreased the use of benzodiazepines, and the difference in the total dose dispensed (mg equivalents of diazepam dispensed in three months) between the pre- and post-intervention period (at 6 and 12 months) were evaluated. RESULTS: Dispensing data from 1561 patients were collected (average age: 69.3 years; 74% women). Twelve months after the intervention, 22.0% (95% confidence interval [95%CI]: 19.9-24.0) discontinued benzodiazepine consumption and 18.8% (95%CI: 16.9-20.8) reduced their consumption. A statistically significant reduction was observed in the total dose dispensed (mean difference: 89mg; 95%CI: 72.2-105.7). CONCLUSION: The Benzoletter is associated with a significant decrease in the consumption of hypnotics. It is a simple and feasible intervention that allows acting on large populations, and it could even be periodically repeated. Controlled studies are required to confirm its effectiveness.

[Facing a dilemma in elderly complex and vulnerable patients: to stop or not to stop prevention?] / Dilemas en la enfermedad crónica avanzada: ¿prevención o desprescripción?

OBJECTIVES: 1-To know the preventive prescription (statin, antiplatelet drugs, bisphosphonates, calcium and vitamin D and Vit B12) of elderly patients previously identified as a CCD (with a complex chronic disease) and ACD (with advanced chronic disease and lifetime expectancy of less than 12 months) who died during 2015. 2-To assess the correct indication of Proton Pump Inhibitors (PPI) to determine potentially avoidable medication. DESIGN: Retrospective observational study. LOCATION: Four Primary Health Centres, Castellar del Vallès (Barcelona). PARTICIPANTS: 128 patients, 70 ACD and 58 PCC. MAIN MEASUREMENTS: Number of drugs at the time of death from the 6 selected group, deprescription (6 months prior to death due to advanced chronic disease), primary or secondary prevention and inappropriate prescription of PPI. RESULTS: Average age of 85'3 years (10,3). 40% took an antiplatelet drug, avoidable in 60% of the ACD, since they did not present any previous cardiovascular episode. 20% of the patients took statins, in which 48% of the cases were primary prevention. The PPI prescription was 67% with inadequate indication for use in 49% of these cases. 20% took calcium / Vitamin D and 1,6% of the ACD a bisphosphonate. There was a 16% deprescription. CONCLUSIONS: A high percentage of our patients with advanced chronic disease and short life expectancy still continue to take preventive and avoidable treatments, potentially dangerous due to their side effects. There is a need to reflect on what we do with these vulnerable patients.

[Deprescribing long-term treatments with bisphosphonates for osteoporosis in primary care in the Basque Country (Spain)]. / Desprescripción de tratamientos de larga duración con bisfosfonatos para la osteoporosis en atención primaria en el País Vasco.

OBJECTIVE: To evaluate the impact of a multifactorial intervention to promote bisphosphonate deprescription after over 5 years of use (BF5y) in a health care organisation (HCO) in Gipuzkoa (Spain) and to compare it with the standard intervention in other HCOs in the Basque Health Service-Osakidetza. METHODS: An 8-month follow-up study (results from before and after) to assess the impact of two interventions. All patients from Osakidetza receiving BF5y treatment (electronic prescription) in July 2013 were included. The standard intervention (9 HCOs) consisted of mailing a consensus statement on BF5y deprescribing and facilitating patient identifiers with BF5y prescription for review by the primary care physician. The multifactorial intervention (Gipuzkoa) also included a local consensus with leading specialists and training sessions in health centres. RESULTS: 18,725 patients were included; 94.7% were women. Standard intervention deprescribing rates ranged from 26.4% (Bilbao) to 49.4% (Araba), being 37.2% overall. The multifactorial intervention deprescribing rate was 44.6%, 7.4% (p <0.0001; 95% confidence interval [95%CI]: 5.4-9.4) higher than standard intervention. Changes to other treatments were less common with the multifactorial intervention, with a difference of 3.7% (p <0.0001; 95%CI: -2.2 to -5.2). CONCLUSIONS: Standard and multifactorial interventions are very effective in reducing unnecessary treatments with bisphosphonates. The multifactorial intervention is more effective than the standard one, although more complex to implement.