Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy

McIntyre, Caitlin; McQuillan, Rory; Bell, Chaim M.; Battistella, Marisa

doi:10.1053/j.ajkd.2017.02.374

Cited by 66 publications

(94 citation statements)

References 24 publications

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“…Deprescribing is becoming an emerging issue [20,21]: it has been shown that it is possible to discontinue a mean of 2.8 drugs in an elderly population without inducing significant adverse effects, improving quality of life and decreasing mortality, moreover allowing significant economic savings in the real context. Current available guidelines lack specific indications for elderly people with CKD: however, a Workgroup has recently been proposed by the European Renal Best Practice, which should provide useful clinical practice patterns for this specific population in the near future [22].…”

Section: Discussionmentioning

confidence: 99%

Acute Kidney Injury and Chronic Kidney Disease in the Elderly and Polypharmacy

et al. 2018

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Background: Acute kidney injury (AKI) incidence is reported to be 10 times higher in aged people. Related to their higher prevalence of chronic kidney disease (CKD), older patients are at high risk of toxic effects driven by drugs. Methods: The demographics, hospitalizations, visits to the Emergency Department, pharmacological therapy, and lab tests were analyzed in 71,588 individuals. Results: Data showed a higher prevalence of AKI as well as CKD in the elderly as compared to the younger group, with an associated very high mortality. A broad number of drugs was prescribed, ranging from 1 to 35, the majority being between 5 and 9 drugs. Conclusion: Elderly patients who developed AKI had a higher number of hospitalizations (underlying frailty), were more likely to progress to more severe stages of CKD and to be affected by other non-renal pathologies (associated comorbidities) and to be given heavier pharmacological prescriptions (polypharmacy).

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Section: Discussionmentioning

confidence: 99%

Acute Kidney Injury and Chronic Kidney Disease in the Elderly and Polypharmacy

et al. 2018

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“…De‐prescribing entails a comprehensive review of medication, identification of potentially inappropriate medication for discontinuation or dose reduction, establishing a plan to safely withdraw medications and patient monitoring after discontinuation . Other medications such as diuretics, proton pump inhibitors, and alpha1‐blockers have been targeted for de‐prescribing among patients receiving maintenance dialysis . The use of these medications was also frequent among Veterans receiving maintenance dialysis.…”

Section: Discussionmentioning

confidence: 99%

“…18 Discontinuation of statin medications in the setting of life-limiting illness may lead to significant improvements in the quality of life and substantial cost savings for patients 19 and de-prescribing of statins has been proposed for patients with dialysis dependent CKD. 20,21 De-prescribing entails a comprehensive review of medication, identification of potentially inappropriate medication for discontinuation or dose reduction, establishing a plan to safely withdraw medications and patient monitoring after discontinuation. 22,23 Other medications such as diuretics, proton pump inhibitors, and alpha1-blockers have been targeted for deprescribing among patients receiving maintenance dialysis.…”

Section: Figurementioning

confidence: 99%

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Statin use among Veterans with dialysis‐dependent chronic kidney disease

Markossian

Kramer

Burge

et al. 2019

Hemodialysis International

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Introduction: The benefits of statin medications in patients receiving maintenance dialysis remains controversial and clinical trials overall have shown no benefit. Potential side effects of statin medications include myalgias, myopathy, and memory loss and risk of side effects associated with statin medications increase with higher statin doses. We examined statin use and statin dose among Veterans with dialysis dependent CKD. Such information may help clinicians modulate medication use and reduce pill burden in appropriate patients. Methods: This cross‐sectional analysis ascertained medication utilization by linking records from the U.S. Department of Veteran's Affairs (VA) Managerial Cost Accounting Pharmacy National Data Extracts and Medicare Part D during calendar year 2013 for Veterans with dialysis‐dependent CKD enrolled in and/or using VA healthcare. The venue of dialysis and patient characteristics were ascertained by linking VA Medical SAS datasets, VA Fee Basis datasets (for non‐VA care paid for by VA), Medicare claims and the United States Renal Data Systems patient core files. Findings: We identified 18,494 Veterans with dialysis‐dependent CKD who were enrolled in and/or used VA healthcare, had no history of kidney transplantation, and were alive on January 1, 2014. More than half (58.1%) of Veterans with dialysis‐dependent CKD used statins and 35.7% of statin utilization was high dose. Statins were the third most commonly prescribed medication after beta blockers (64.8%) and phosphate binders (64.5%). Discussion: Statins are a commonly prescribed medication among Veterans receiving maintenance dialysis and approximately one‐third of statin utilization is high dose in this population. Future studies should examine patient preferences, comorbidities, and dialysis characteristics that impact the risks and benefits of statin use in order to identify those patients who will or will not benefit from continued statin use.

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“…At the end of this medication review, physicians should limit the number of medications as far as possible, but the development of an algorithm ensuring that the highest priority drugs are prescribed in this population is essential. Limiting the number of medications should also improve patient adherence but deprescribing is a real challenge (49,50).…”

Section: Discussionmentioning

confidence: 99%

Medication Burden And Inappropriate Prescription Risk Among Elderly With Advanced Chronic Kidney Disease

Roux-Marson

Baranski

Fafin

et al. 2019

Preprint

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Background Elderly patients with chronic kidney disease (CKD) frequently present comorbidities that put them at risk of polypharmacy and medication-related problems. This study aims to describe the overall medication profile of patients aged ≥ 75 years with advanced CKD from a multicenter French study and specifically the renally (RIMs) and potentially inappropriate-for-the-elderly medications (PIMs) that they take. Methods This is a cross-sectional analysis of medication profiles of individuals aged ≥ 75 years with eGFR < 20 ml/min/1.73m2 followed by a nephrologist, who collected their active prescriptions at the study inclusion visit. Medication profiles were first analyzed according to route of administration, therapeutic classification. Second, patients were classified according to their risk of potential medication-related problems, based on whether the prescription was a RIM or a PIM.RIMs and PIMs have been defined according to renal appropriateness guidelines and to Beer's criteria in the elderly. RIMs were subclassified by 4 types of category : (a) contraindication; (b) dose modification is recommended based on creatinine clearance (CrCl); (c) dose modification based on CrCl is not recommended but a maximum daily dose is mentioned, (d) no specific recommendations based on CrCl : "use with caution", "avoid in severe impairment", "careful monitoring of dose is required" "reduce the dose". Results We collected 5196 individual medication prescriptions for 556 patients, for a median of 9 daily medications [7][8][9][10][11]. Antihypertensive agents, antithrombotics, and antianemics were the classes most frequently prescribed. Moreover, 77.0% of patients had at least 1 medication classified as a RIM. They accounted 31.3% of the drugs prescribed and 9.25% was contraindicated drugs. At least 1 PIM was taken by 57.6% and 45.5% of patients had at least one medication classified as RIM and PIM. The prescriptions most frequently requiring reassessment due to potential adverse effects were for proton pump inhibitors and allopurinol. The PIMs for which deprescription is especially important in this population are rilmenidine, long-term benzodiazepines, and anticholinergic drugs such as hydroxyzine. Conclusion We showed potential drug-related problems in elderly patients with advanced CKD. Healthcare providers must reassess each medication prescribed for this population, particularly the specific medications identified here.

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Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy

Cited by 66 publications

References 24 publications

Acute Kidney Injury and Chronic Kidney Disease in the Elderly and Polypharmacy

Acute Kidney Injury and Chronic Kidney Disease in the Elderly and Polypharmacy

Statin use among Veterans with dialysis‐dependent chronic kidney disease

Medication Burden And Inappropriate Prescription Risk Among Elderly With Advanced Chronic Kidney Disease

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