Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

Abstract

Background: End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs). Objective: To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms. Design: Secondary analysis of a cluster randomized clinical trial. Setting: Medical units in 11 acute care hospitals in Canada. Patients: The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis. Measurements: The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing. Methods: Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing. Results: There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents. Limitations: This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions. Conclusion: MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study

“…Not applicable (a waiver of consent was obtained for this quality improvement project; medication reviews are considered best practice in our institution for patients on dialysis). 1…”

“…Patients with end-stage kidney disease (ESKD) who require dialysis are prescribed an average of 10 to 12 daily medications, often by 4 to 5 different clinicians, amounting to as many as 19 pills per day. [1][2][3][4] The dialysis patient population has one of the heaviest pill burdens of all chronic conditions due to concurrent treatment of co-existing conditions such as hypertension, vascular disease, and diabetes, 4 as well as treatment of complications of ESKD itself (eg, increased propensity for bleeding, bone mineral metabolism disorders, pruritus, pain, and insomnia).…”

“…More than 90% of dialysis patients take 5 or more medications (polypharmacy), 2,5 contributing to medication overload. 6,7 Furthermore, more than 90% are prescribed 1 or more potentially inappropriate medications (PIMs) 1,4,8 ; PIMs are associated with an increased risk of harm (often through adverse drug events, ADEs) or they have a relatively low chance for benefit and merely contribute to a patient's pill burden. 2,4,7 Adverse drug events such as falls, fractures, and cognitive impairment can occur as a direct result of PIMs, or due to drug-drug interactions, both of which are more common with polypharmacy.…”

Challenges to Implementing Environmentally Sustainable Kidney Care in LMICs: An Opinion Piece

“…Deprescribing, the process of tapering, stopping, discontinuing, or withdrawing drugs that are not indicated or have poor evidence of efficacy can also make a significant difference by decreasing the environmental burden associated with manufacturing, supply chain, and disposal of drugs. 43 - 45 Approaches to incremental dialysis can also help reduce waste generation. 46 , 47 Cultivating local expertise and generating guidelines to inform other HCPs can help champion ESKC.…”

Benefits of nirmatrelvir–ritonavir remain unproven for some populations

“…Patients on hemodialysis are prescribed a median of 14 medications. 3 As such, a careful review of medications should be undertaken; the risk of toxic effects from a higher prevalence of drug–drug interactions, compounded by reduced renal clearance, should be taken into consideration.…”