The MedSafer Study—Electronic Decision Support for Deprescribing in Hospitalized Older Adults

McDonald, Emily G.; Wu, Pin; Rashidi, Babak; Wilson, Marnie Goodwin; Bortolussi‐Courval, Émilie; Atique, Anika; Battu, Kiran; Bonnici, André; Elsayed, Sarah; Wilson, Allison Goodwin; Papillon‐Ferland, Louise; Pilote, Louise; Porter, Stephen C.; Murphy, Johanna; Ross, Sydney B.; Shiu, Jennifer; Tamblyn, Robyn; Whitty, R.; Xu, Jieqing Jessica; Fabreau, Gabriel; Haddad, Taleen; Palepu, Anita; Khan, Nadia; McAlister, Finlay A.; Downar, James; Huang, Allen; MacMillan, Thomas E.; Cavalcanti, Rodrigo B.; Lee, Todd C.

doi:10.1001/jamainternmed.2021.7429

Cited by 65 publications

(148 citation statements)

References 45 publications

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“…The MedSafer [18] trial enrolled 5698 patients 65 years and older who were taking 5 or more medications and survived to hospital discharge. The median age of the cohort was 78 years (IQR 71-86) and 50.2% or participants were female.…”

Section: Resultsmentioning

confidence: 99%

“…[12] For this COVID-SAFER: Nirmatrelvir-ritonavir study, we analyzed data from the 5698 patient cluster randomized MedSafer trial, which ran from August 2017 to January 2020. [14] Briefly, inclusion criteria identified patients 65-years and older, taking five or more medications, admitted to one of the 11 study hospitals. Data pertaining to medications and comorbidities were analyzed with the MedSafer deprescribing software.…”

Section: Methodsmentioning

confidence: 99%

“…[15][16][17] MedSafer generates a prioritized, individualized deprescribing report according to the perceived level of medication harm (high, intermediate, or low risk/little added value), and provides the rationale for deprescribing with appropriate tapering protocols where required. [18] The MedSafer trial compared the provision of individualized deprescribing opportunity reports to usual care for the primary outcome of prevention of post-discharge adverse drug events (ADEs) and, among several secondary outcomes, the augmentation of deprescribing of PIMs at hospital discharge.…”

Section: Methodsmentioning

confidence: 99%

“…Information on previous presentation of the information reported in the manuscript: The MedSafer study [18] contains the primary data from which the present study was derived.…”

Section: Disclaimers: None To Disclosementioning

confidence: 99%

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COVID-SAFER: Deprescribing Guidance for Nirmatrelvir-ritonavir Drug Interactions in Older Adults

Ross

Bortolussi‐Courval

Hanula

et al. 2022

Preprint

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ImportanceOlder adults, at high-risk of developing complications from COVID-19, could benefit from nirmatrelvir-ritonavir, an oral antiviral treatment for outpatients at high risk of complications from COVID-19; however, due to its potent CYP3A4 inhibition, nirmatrelvir-ritonavir is associated with many drug-drug interactions (DDI).ObjectivesIdentify how common DDIs are between nirmatrelvir-ritonavir, common medications, and PIMs in older adults with polypharmacy. Craft anticipatory deprescribing guidance for PIMs that interact with nirmatrelvir-ritonavir to help prioritize deprescribing resources, and increase the proportion of older adults potentially benefitting from treatment.DesignIn this secondary analysis, we retrospectively analyzed all patients in the MedSafer cluster randomized deprescribing trial (N=5698 participants) to investigate the proportion of older adults (age >65) with polypharmacy (≥5 usual home medications) who would be ineligible for treatment with nirmatrelvir-ritonavir due to pre-existing DDIs.SettingThe setting of the primary study was in medical inpatient units at 11 Canadian acute care hospitals.ParticipantsHospitalized persons, age 65 years and older, on 5 or more daily home medications, with an expected survival of 3 months or longer were included in this secondary analysis.Main outcomes and measuresWe identified the prevalence of (PIMs), as defined by the MedSafer software. We then developed deprescribing guidance, so clinicians could proactively deprescribe in an effort to increase the proportion of older adults eligible for safe treatment with nirmatrelvir-ritonavir in the event of a SARS-CoV-2 infection.ResultsOf 5698 participants, a total of 3869 (68%) were taking a medication with a known nirmatrelvir-ritonavir DDI, and of these 823 (21%) had at least one PIM. Of 823 PIMs, 627 (76%) were medications with a known high risk DDI and 213 (26%) were considered moderate risk DDIs with nirmatrelvir-ritonavir. Many of the PIMs required “advanced deprescribing” and could not simply be stopped, held, or adjusted at the time of nirmatrelvir-ritonavir receipt.Conclusions and relevanceOlder adults are at high risk of developing severe complications from COVID-19. Deprescribing PIMs in advance of a COVID-19 infection could increase the proportion of older adults who can safely receive nirmatrelvir-ritonavir, in addition to the usual benefits observed with medication management.Impact StatementWe certify that this work is novel. This timely clinical investigation explores the unforeseen consequences of polypharmacy and the use of potentially inappropriate medication in older adults during the COVID-19 pandemic. This manuscript addresses the many drug-drug interactions between nirmatrelvir-ritonavir, an antiviral treatment for COVID-19, and potentially inappropriate medications in older adults with polypharmacy from the MedSafer cluster randomized trial. Our work highlights that the pandemic has created an even greater urgency to examine the medication lists of older adults and proactively deprescribe to improve the safety and tolerability of different COVID-19 treatments.Key PointsQuestion: How does polypharmacy affect the eligibility of older adults to receive Nirmatrelvir-ritonavir?Findings: 68% of older adults in the MedSafer cluster randomized trial had a DDI with nirmatrelvir-ritonavir, and 21% were taking at least 1 potentially inappropriate medication.Meaning: Due to its potent CYP3A4 inhibition, nirmatrelvir-ritonavir is associated with many drug-drug interactions (DDI).

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…Information on previous presentation of the information reported in the manuscript: The MedSafer study [18] contains the primary data from which the present study was derived.…”

Section: Disclaimers: None To Disclosementioning

confidence: 99%

See 2 more Smart Citations

COVID-SAFER: Deprescribing Guidance for Nirmatrelvir-ritonavir Drug Interactions in Older Adults

Ross

Bortolussi‐Courval

Hanula

et al. 2022

Preprint

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“…A recent randomized controlled trial using MedSafer in hospitalized patients demonstrated an increase in the amount of PIMs deprescribed compared with usual care alone, with a neutral impact on short-term ADEs in the 30-day post-hospital discharge. 23 Although polypharmacy and ADEs are well documented in patients on dialysis, few studies have reported on deprescribing interventions and follow-up outcomes for this population. Thus, the aims of this study were to (1) characterize the prescription patterns in a cohort of hospitalized patients with polypharmacy receiving maintenance intermittent dialysis, (2) identify PIMs that were flagged by MedSafer and subsequently deprescribed, and (3) describe the clinical outcomes following deprescribing in this subgroup of the largest inpatient deprescribing trial published to date.…”

Section: Introductionmentioning

confidence: 99%

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

Moryousef

Bortolussi‐Courval

Podymow

et al. 2022

Can J Kidney Health Dis

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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.

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Educational Brochures for Deprescribing

Anderson

2024

JAMA Intern Med

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The MedSafer Study—Electronic Decision Support for Deprescribing in Hospitalized Older Adults

Cited by 65 publications

References 45 publications

COVID-SAFER: Deprescribing Guidance for Nirmatrelvir-ritonavir Drug Interactions in Older Adults

COVID-SAFER: Deprescribing Guidance for Nirmatrelvir-ritonavir Drug Interactions in Older Adults

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

Educational Brochures for Deprescribing

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