Tuesday, 14 June 2016

ClinicSpeak: deprescribing in multiple sclerosis

Are  you taking to many medications? #ClinicSpeak #MSBlog 

"What never ceases to amaze me is the number of medications pwMS accumulate on their MS journey. Some patients of ours are taking upwards of 20 medications per day excluding OTC (over-the-counter) complementary medications. They accumulate medications for all their symptomatic problems; we call these con-meds, or concomitant medications. Often medications are added to treat side effects of other medications, for example anti-cholinergic drugs for bladder symptoms make constipation worse, which necessitates adding in laxatives. Anti-spastic drugs cause sedation and worse fatigue, necessitating something for fatigue. Often pwMS forget why drug x was started. It is therefore important for you to engage with all the medications you are prescribed and to understand why you are taking them."

"More times than not your con meds can be rationalised and you can stop taking some of them; we call this de-prescribing. Interestingly, I have noticed many pwMS who have started on highly-effective DMTs self de-prescribe as their symptoms improve spontaneously. In fact, I have asked several Pharma companies to look at their databases to see if de-prescribing occurs more commonly on effective treatments compared to placebo, or less effective comparators. If yes, this can be used as an economic argument to use more effective treatments sooner."
"The article below describes the issues around de-prescribing in the elderly. The issues are similar to that in the pwMS. If you think you are taking too many medications discuss this with your family doctor, neurologist or clinical nurse specialist. You should understand why you are taking each medicine and whether it causes any side effects and whether or not it is likely to interact with your other medications. You can't be a passive recipient of medication; you need to be active. If in doubt challenge your healthcare professionals about why you are on all your medications."




Jansen et al. Deprescribing through shared decision making. BMJ 2016;353:i2893

Excerpts:

...... Too much medicine is an increasingly recognised problem,and one manifestation is inappropriate polypharmacy ..... 

...... Polypharmacy is usually defined as taking more than five regular prescribed medicines. It can be appropriate (when potential benefits outweigh potential harms) but increases the risk of pwMS experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission....

.... There is limited evidence to inform polypharmacy in pwMS, especially those with multimorbidity, cognitive impairment, or disability.....

.....  Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life.....

.... Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.....

..... Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms. When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing. However, shared decision making in this context is not easy, and there is little guidance on how to do it....

..... We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions.... 

Process for deprescribing:

Step 1: creating awareness that options exist

Step 2: discussing the options and their benefits and harms

Step 3: Exploring patient preferences for the different options

Step 4: making the decision

3 comments:

  1. I'm not on a DMT, having what appears to be mainly progressive MS, and I take no medications apart from over the counter painkillers occasionally. I've been offered presriptions for this and that, but I see avoiding drugs as part of protecting my excellent general health, which is what is carrying me.

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    Replies
    1. With all due respect, what does "mainly progressive MS" mean? Most progressive MSers are still taking an highly effective DMT such as Natalizumab even though studies were negative. When you say "I've been offered prescriptions for this and that, but I see avoiding drugs as part of protecting my excellent general health..." does that mean you do not have MS related issues such as: walking difficulties, spastic bladder, neuropathic pain, spasticity, etc.? Patients take meds to ameliorate MS related issues. It is good that you have excellent heath but others need meds for their MS symptoms.

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    2. " It is good that you have excellent heath but others need meds for their MS symptoms."

      I do not dispute that and have said nothing to the contrary.

      I'm not going to go into details about my MS. Suffice to say I'm doing the right thing for me, which includes refusing drugs for symptoms. That will not be the right thing for everyone. Of course not - I can speak for no one but myself.

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