Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review

Abstract

Due to both age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proactive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individual patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient, clinician, and system-level challenges to the deprescribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, as well as system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.

Enhancing medication management in hemodialysis patients: Exploring the impact of patient-centered pharmacist care and motivational interviewing

“…It can be said the type MRPs identified may differ by country, settings of HD and physician experience. The less acceptance rate might be due to the challenges communicating with other clinical team members owing to inadequate time, lack of clear evidence-based guidelines or studies and conflicts between the role of the pharmacist, physician, and specialists that may also impair deprescribing or medication adjustments [ 27 , 28 ]. Additionally, physicians were reluctant to accept many of the interventions because they might require referrals to other specialists to reevaluate the individual patient’s requirements.…”

Deprescribing in Dialysis: Operationalizing “Less is More” Through a Multimodal Deprescribing Intervention

“…Deprescribing is an exemplar of this proverb and describes the process of deliberately withdrawing medications, with the aim of reducing pill burden and improving health and quality of life. 1 Deprescribing may mitigate multiple adverse events associated with polypharmacy, including falls, cognitive disturbances, hospitalizations and mortality risk. 2 …”

“…These efforts must incorporate contextual factors unique to people living with kidney disease, including a rapidly evolving pharmaceutical armamentarium, dosing adjustments as eGFR declines, emerging multidisciplinary kidney care models, and frequent health care engagement and associated cascading prescribing patterns. 1 , 6 , 7 …”

“…Notably, authors also report that 29% of deprescribing in the intervention unit resulted from newer clinical algorithm rules specified for dialysis that were incorporated into the MedSafer intervention, adapted from a prior dialysis-specific deprescribing guidelines developed by Lefebvre et al 15 that leverage widely accepted PIM-guidelines including STOPP-STARRT (Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment) and BEERS criteria. 1 …”

“…Provision of introductory emails regarding the intervention, as well as delivery of MedSafer deprescribing clinician report examples to intervention group nephrologists, may have also enhanced intervention uptake and perceptions of usability. Finally, MedSafer incorporates several components of a recently described decision-making framework, List Evaluate Shared Decision Making and Support, 1 by leveraging the electronic health record to create an accurate medication list, providing a clear review of medications for deprescribing with risk-stratified categories, and through delivery of patient-facing EMPOWER brochures, which prompt patients to consider their need for specific PIMs and their associated risks.…”