Intervention by Pharmacists May Effectively Reduce Use of Inappropriate Medications in the Elderly

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Inappropriate prescriptions to older individuals can lead to higher hospitalization rates and adverse events, and remain a concern.
Inappropriate prescriptions to older individuals can lead to higher hospitalization rates and adverse events, and remain a concern.

An intervention by community pharmacists consisting of sending elderly patients educational information on deprescribing of inappropriate medications resulted in higher levels of discontinuation of inappropriate medications within 6 months compared with in patients who received usual care, according to a study published in JAMA.

Inappropriate prescriptions to older individuals can lead to higher hospitalization rates and adverse events, and remain a concern. A collaborative effort among patients, physicians, and pharmacists to optimize medication management with the aid of communication regarding potential harm and safer alternatives may help mitigate these concerns.

The Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE) study (Clinicaltrials.gov identifier: NCT02053194) was a 2-group cluster randomized multiblinded trial conducted in Quebec, Canada, between February 2014 and September 2017. 

A total of 69 community pharmacies were randomly assigned to provide an intervention (n=34) or usual care (control; n=35). The intervention consisted of providing patients ≥65 years who were prescribed 1 of 4 Beers Criteria medications (ie, sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs [NSAIDs]) deprescribing information (n=248; 61.7% women) or usual care (n=241; 70.1% women). Study participants were followed for 6 months.

Intervention group pharmacists provided patients a deprescribing brochure and sent their physicians a pharmaceutical opinion letter advocating for deprescribing inappropriate medications. Usual care pharmacists offered conventional care without educational intervention. The primary outcome was inappropriate medication discontinuation at the 6 month-follow-up.

Of 489 enrolled patients (mean age, 75 years; 66% women; 23% aged ≥80 years), 437 individuals (89%) completed the study (n=219 [88%] received intervention; n=218 [91%] received usual care). After 6 months, inappropriate medications were discontinued by 106 patients (42.7%) who had received the intervention and by 29 patients (12.0%) who had received usual care (risk difference, 31%; 95% CI, 23%-38%; number needed to treat [NNT], 3.22; relative risk [RR], 3.55).

Sedative-hypnotic drugs were stopped by 63 (43.2%) of 146 patients in the intervention group compared with 14 (9.0%) of 155 patients in the control group (risk difference, 34%; 95% CI, 25%-43%; NNT, 2.94; RR, 4.78). For glyburide, 30.6% vs 13.8% of patients, respectively, had discontinued the medication (risk difference, 17%; 95% CI 2%-31%; NNT, 5.88; RR, 2.22). NSAIDs were discontinued by 57.6% vs 21.7% of patients in the intervention and control groups, respectively (risk difference, 35%; 95% CI 10%-55%; NNT, 2.86; RR, 2.64). The P value for the interaction was .09. Antihistamines were not analyzed because of a small sample size (n=12).

A total of 37 patients who discontinued an inappropriate medication replaced it with another drug. Of participants taking sedative-hypnotic drugs, 38% who tried tapering reported experiencing withdrawal symptoms. No serious adverse events that required hospitalization were reported.

Study limitations include a lack of information regarding extra clinic visits or telephone contacts, limited follow-up time, and uncertainty regarding additional factors that may have contributed to drug cessation.

"A pharmacist-led intervention has the potential to reduce prescriptions for inappropriate medication in older adults," concluded the authors.

Conflicts of Interest Disclosures

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Martin received a bursary from the Michel Saucier Endowed Chair in Pharmacology, Health and Aging of the Faculty of Pharmacy of the Université de Montréal. Dr Ahmed and Dr Tannenbaum are clinician-scientists funded by the Fonds de Recherche en Santé de Quebec. No other disclosures were reported.

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Reference

Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adultsJAMA. 2018;320(18):1889-1898.

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