Prescription Flip-Side:
Guidelines for medication withdrawal
Newswise — Although thousands of
scientific papers evaluate and compare new and established drugs
each year, providing evidence to help doctors prescribe safe and
effective doses, almost no studies focus on when or how to stop
these medications, even late in life.
In the March 27, 2006, issue of
the Archives of Internal Medicine, four University of Chicago
physicians propose the first general framework for withholding or
discontinuing medications, adding life expectancy, goals of care,
treatment targets and time until benefit to the usual equation of
drug plusses and minuses.
"Our framework was designed to
help patients and physicians decide when to stop taking even safe
and effective drugs in situations that are often radically different
from those where the medications were started," said geriatrician
Holly Holmes, M.D., instructor of medicine at the University of
Chicago and lead author of the study.
"We wanted to provide a road map,"
she said, "that would steer people away from the prescribing cascade
that is common for patients late in life and guide them past the
barriers that prevent removal of treatments that may no longer be
effective."
The impetus for the guidelines
came from some misguided advice. The authors care for patients at a
nursing home. The pharmacy that supplies the nursing home monitors
physician-prescribing practices and offers suggestions. After one
review, the pharmacy sent a fax pointing out that, according to
accepted guidelines, two patients at the nursing home ought to be
taking a statin -- a cholesterol-lowering drug that can, over time,
reduce the risk of heart attack.
"One of those patients was more
than 100 years old, quite frail, with advanced cancer and multiple
other medical problems," Holmes said. "The other one was dead. It
made us wonder whether something wasn't missing from those
guidelines."
There are well-tested algorithms
for prescribing drugs and avoiding inappropriate medications in the
elderly, but as the authors combed through them with their frail
older patients in mind they noticed that none considered when
medications that might have previously been appropriate should be
discontinued.
"Most drug studies tell you how to
treat the chart, how to treat the numbers," said co-author Caleb
Alexander, M.D., assistant professor of medicine and a member of the
Center for Clinical Medical Ethics at the University of Chicago,
"but they don't always help you treat the patient. We set out to
fill some of those gaps."
One of those gaps was prognosis.
Drugs with long-term benefits, such as those for high blood pressure
or elevated cholesterol, provide no immediate relief, are seldom
entirely without side effects and can be quite expensive, especially
for the elderly who often take many different drugs. Such
medications may be appropriate for a 65-year old with mild heart
disease but at some point in the next 25 years patient and physician
may have to overcome what the authors refer to as "clinical inertia"
and rethink that initial decision.
The authors suggest four criteria
for doctors considering adding -- or subtracting -- a drug from an
elderly patient's therapeutic arsenal. First is to calculate the
patient's life expectancy, based on actuarial charts and modified by
the patient’s current health status and history. Second is to weigh
the time to benefit. Pain relief may be immediate but some
preventive medications, such as a statin, may not provide any
benefit for years. Third is to work with the patient and family to
determine the goals of care, a shifting balance of prevention,
treatment and palliation. Fourth is to define treatment targets,
such as relief of specific symptoms, that agree with the goals of
care.
Even when it makes clinical sense
to take patients off of a medicine, the authors note, it can be
emotionally challenging. Sixty-five percent of all office visits end
with the granting of a prescription. "It's often the closing moment
of a caring interaction," Holmes said. "It seals the deal. It's not
the same when you have to take it away."
Nonetheless, the authors say, it
is necessary. "Medication discontinuation, when done right, can
decrease costs, simplify prescription regimens, decrease adverse
drug events and focus therapy for maximum benefit," Alexander said.
"Evidence-based medicine has
changed the way physicians practice, but it seems to have had tunnel
vision when it comes to withdrawing drugs," Holmes said. "The
discontinuation of medications is a neglected science. It's not an
area that the pharmaceutical companies are looking to fund."
Additional authors of this paper
include University of Chicago geriatricians Greg Sachs, professor of
medicine and section chief of geriatrics, and Deon Cox Hayley,
associate professor of medicine and medical director of the
Windermere Senior Health Center.