Deprescribing of Symptomatic Medications in Rehabilitative or Subacute Care Patients

Not Applicable

• Conditions: Polypharmacy; Adverse Drug Reaction
• Interventions: Other: Deprescribing intervention

• Registration Number: NCT03354845
• Lead Sponsor: Bright Vision Hospital

Brief Summary

Deprescribing is a systematic method of withdrawing potentially inappropriate or unnecessary medications and is warranted in the elderly due to the high prevalence of polypharmacy. In particular, symptomatic control medications, such as acid suppressants, laxatives and painkillers, are frequently prescribed and continued, though such medications are rarely needed on a long-term basis.

Therefore, the study objectives were to determine the cost savings, effects and feasibility of implementing a systematic process of deprescribing medications for symptomatic management, namely, acid suppressants, laxatives, analgesics, and antiemetics.

Detailed Description

Deprescribing is a systematic process of identifying and withdrawing drugs, which are potentially or currently causing more harm than benefit to patients, based on each individual patient's condition, treatment goals and level of functioning. Deprescribing needs to be patient-centric with shared decision-making between patients or caregivers and the multidisciplinary care team. Five distinct steps of deprescribing have been elucidated, and they comprise: 1) performing a comprehensive patient medical/medication history; 2) considering the overall risk and appropriateness of drugs; 3) assessing possibility of and planning drug discontinuation; 4) initiating and documenting drug discontinuation; and 5) monitoring effects and providing patient support.

Deprescribing is necessary in elderly aged 65 years and above due to the higher prevalence of polypharmacy and unnecessary and inappropriate medication use, compared to younger age groups. In Singapore, statistics from an acute restructured hospital in 2013 showed that 50 percent or more of inpatients were discharged with at least five chronic medications.

The discontinuation of medications has been trialled in earlier studies without causing significant adverse effects or symptom recurrence. Positive outcomes demonstrated include enhanced cognition, improved health and reduced falls. However, it is necessary to investigate the effects and feasibility of deprescribing in the present local setting, where healthcare perceptions, and associations between medication discontinuation and patient clinical outcomes may be different from other studied populations.

Therefore, this randomized controlled intervention study was conducted in a community hospital in Singapore to determine the cost savings, effects and feasibility of implementing a systematic process of deprescribing medications for symptomatic management, namely, acid suppressants, laxatives, analgesics, and antiemetics.

Study Timeline

• Study Start: 2016-04-05
• Primary Completion: 2017-02-21
• Status Verified: 2017-11
• Study First Submitted: 2017-11-22
• Study First Submitted QC: 2017-11-22
• Last Update Submitted: 2017-11-22
• Study First Posted: 2017-11-28
• Last Update Posted: 2017-11-28
• Study Completion: 2018-01-31

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 200

Inclusion Criteria

• All patients, regardless of age, who were on at least one of the following target symptomatic control medications for deprescribing: acid suppressants/proton pump inhibitors (PPIs), laxatives, analgesics (paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), codeine, tramadol) and antiemetics

Exclusion Criteria

• Patients with terminal illness or cancer and patients with documented clinically significant dementia and had no accompanying caregiver

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Deprescribing intervention group	Deprescribing intervention	The five-step patient-centred deprescribing process was utilized in the intervention group.

Primary Outcome Measures

Name	Time	Method
Cost savings	6 weeks	Reduction in the cost of one month of medications

Secondary Outcome Measures

Name	Time	Method
Feasibility of implementation	6 weeks	Time required to complete the deprescribing process and the limitations and challenges encountered
Number of medications	6 weeks	Reduction in the total number of medications
Change in bowel movement following deprescribing	6 weeks	Adverse effect of constipation indicated by no bowel movement in the past two days (BNO ≥2/7)
Adverse consequences of deprescribing	6 weeks	Symptom recurrence, adverse drug withdrawal events (ADWEs), and the need for deprescribed medications to be restarted or initiation of new symptomatic control medications after deprescribing