Indianapolis, IN—Deploying pharmacists as deprescribing care coordinators decreased inappropriate prescriptions of anticholinergics by 73% while reducing cumulative use of the drugs by as much as 70%.
That is according to a study from the Regenstrief Institute, Purdue University College of Pharmacy, and Indiana University School of Medicine. The report in the Journal of the American College of Clinical Pharmacy focused on anticholinergics, which are frequently prescribed for depression, urinary incontinence, and many other conditions common in older adults.
The problem, according to the authors, is that the medications also affect the brain by blocking acetylcholine, a nervous-system neurotransmitter that influences memory, alertness, and planning skills.
"Our new study is important, necessary preliminary work, enabling us to test whether deprescribing these drugs improves clinical outcomes," stated lead investigator Noll Campbell, PharmD, MS, of the Regenstrief Institute and Purdue College of Pharmacy.
Dr. Campbell has been developing pharmacist-centric delivery models to successfully switch patients to safer drugs. "Tackling deprescribing has not been easy," he noted. "That pharmacist-centric deprescribing models work so well does not surprise me because pharmacists are well suited for the task. They are knowledgeable about medications, often have a close relationship with the patients and are well trained to communicate with providers."
The researchers developed two pharmacist-focused deprescribing models. In the first, a face-to-face model, pharmacists met with and monitored older adult patients who were being seen in an aging-brain care clinic. The second model, which involved pharmacist outreach via telephone to a generally older adult patient population and encouraged safer medications, was found to be less effective in reducing exposure to anticholinergics. Even the second method was more effective than other methodologies, including clinician alerts in electronic health records (EHRs).
The researchers embarked on the study because deprescribing interventions delivered through EHRs have not significantly reduced the use of high-risk anticholinergics in prior trials. "Pharmacists have been identified as ideal practitioners to conduct deprescribing, however little experience beyond collaborative consult models has been published," the researchers explained.
The patients receiving the clinic-based pharmacy model were aged 55 years and older (mean age 68 years) and referred for deprescribing at a specialty clinic, whereas patients receiving the telephone-based pharmacy model were aged 65 years and older (mean age 73 years) and received calls from a clinical pharmacist for deprescribing without referral. For research purposes, "deprescribing" was defined as a discontinuation or dose reduction reported either in clinical records or through self-reporting.
The results indicated that—among the 24 medications deemed eligible for deprescribing—23 (96%) were deprescribed through the clinic-based deprescribing model, which resulted in a 93% reduction in median annualized total standardized dose (TSD). Most (56%) of the patients lowered their annualized exposure below a cognitive risk threshold, and only four (17%) of medications were represcribed within 6 months.
With the call-past model—among 24 medications deemed eligible for deprescribing—12 (50%) were deprescribed. No change was identified in the median annualized TSD, although the annualized TSD was lowered below a cognitive risk threshold in 46% of the patients and no medications were represcribed within 6 months.
In the study of mostly women, few withdrawal symptoms or adverse events were reported in either group.
"Pharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in primary care older adults, yet further work is needed to understand the impact on clinical outcomes," the researchers pointed out.
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