DE-PRESCRIBING
What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?
In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of Required Learning Resources in this course.
Note: APA style format guidelines will apply.
Patient Examples:
Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.
Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.
Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.
Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”
ASSIGNMENT
Answer the following questions using the patient examples described above.
Patient 1
· What are the concerns of the patient remaining on the opioid medication and clonazepam?
· How might you educate the patient about these risks and concerns?
The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:
· How would you instruct the patient to taper off clonazepam?
· What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
· How would you start the new recommended psychotropic medication for the patient?
· Discuss one legal, ethical, or social consideration with the treatment plan.
Patient 2
· The patient reports withdrawal symptoms when previously tapering off the alprazolam. What symptoms are common withdrawal symptoms from this medication?
· Provide the patient education of withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt patient should seek medical attention.
· Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?
· What is the dose you would prescribe and how would you taper off the medication?
Patient 3
· Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.
· Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breast feed for 6 months postpartum.
· The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.
· The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.
Patient 4
· Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
· How would you evaluate the patient for these side effects?
· The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
· Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.
### Deprescribing: Importance and Safe Practices
Deprescribing is a critical aspect of patient care, especially for those on long-term medications. It involves the planned and supervised process of dose reduction or stopping medications that may no longer be beneficial or might be causing harm. This practice is essential for minimizing polypharmacy, reducing adverse drug reactions, and improving patient outcomes. The process requires careful consideration, patient education, and monitoring to ensure safety and effectiveness.
### Patient 1: 36-Year-Old Male on Opioid and Clonazepam
#### Concerns of Remaining on Opioid and Clonazepam
1. **Risk of Addiction**: Both opioids and benzodiazepines are highly addictive, and long-term use can lead to dependence and withdrawal issues.
2. **Cognitive and Motor Impairment**: The combination can impair cognitive functions and motor skills, increasing the risk of accidents.
3. **Respiratory Depression**: Combining these medications can potentiate respiratory depression, which can be fatal.
#### Educating the Patient on Risks and Concerns
It is crucial to inform the patient about the potential for addiction, the dangers of cognitive and motor impairment, and the risk of respiratory depression. Emphasize the importance of adhering to prescribed dosages and the potential need for monitoring.
#### Tapering Off Clonazepam
A gradual tapering schedule is recommended to avoid withdrawal symptoms:
– Reduce the dose by 0.25 mg every 1-2 weeks.
– Monitor for withdrawal symptoms and adjust the tapering schedule as needed.
#### Alternative Medication for Panic Attacks
A selective serotonin reuptake inhibitor (SSRI) like sertraline or paroxetine can be effective for panic attacks. SSRIs have a favorable safety profile and are less likely to cause dependence.
#### Initiating the New Medication
Start the SSRI at a low dose to minimize side effects and gradually increase:
– Sertraline: Start at 25 mg once daily, increasing to 50 mg after one week based on tolerance and response.
– Monitor the patient closely for efficacy and side effects.
#### Legal, Ethical, or Social Consideration
The ethical consideration of patient autonomy must be respected. The patient’s informed consent should be obtained, ensuring they understand the risks and benefits of both tapering clonazepam and starting the new medication.
### Patient 2: 42-Year-Old Female on Alprazolam
#### Common Withdrawal Symptoms
– **Mild Symptoms**: Anxiety, insomnia, restlessness, and irritability.
– **Severe Symptoms**: Seizures, hallucinations, and psychosis.
#### Patient Education on Withdrawal Symptoms
– **Mild Symptoms**: Educate the patient that mild symptoms like anxiety and restlessness are common but usually manageable.
– **Severe Symptoms**: Inform the patient that severe symptoms such as seizures require immediate medical attention.
#### Transition to a Longer-Acting Benzodiazepine
Diazepam is often used due to its longer half-life:
– Convert alprazolam 1 mg BID to diazepam 10 mg BID.
– Taper diazepam by 2 mg every 1-2 weeks based on patient tolerance.
### Patient 3: 24-Year-Old Pregnant Female on Lorazepam
#### Risks, Benefits, and Side Effects of Continuing Lorazepam
– **Risks**: Teratogenic effects, neonatal withdrawal syndrome, and sedation in the newborn.
– **Benefits**: Effective management of anxiety symptoms.
– **Side Effects**: Drowsiness, dizziness, and potential developmental issues in the fetus.
#### Alternative Medications for Anxiety During Pregnancy
– **SSRIs (e.g., sertraline)**: Generally considered safe during pregnancy, though there are some risks of neonatal adaptation syndrome.
– **Buspirone**: Less effective than benzodiazepines but safer in pregnancy.
#### Tapering Off Lorazepam
– Reduce the dose by 0.5 mg every week.
– Monitor for withdrawal symptoms and adjust the tapering schedule as needed.
#### Education on Risks of Untreated Anxiety
– Untreated anxiety can lead to poor prenatal care, increased risk of preterm labor, and negative postpartum outcomes.
– Stress the importance of addressing anxiety through safe means, including therapy and lifestyle modifications.
### Patient 4: 71-Year-Old Male on Multiple Medications
#### Risks of Benzodiazepines in the Elderly
– **Cognitive Impairment**: Increased risk of dementia.
– **Falls and Fractures**: Due to sedation and motor impairment.
– **Physical Dependence**: Greater likelihood of withdrawal symptoms.
#### Evaluating for Side Effects
– Conduct cognitive assessments and fall risk evaluations regularly.
– Review the patient’s medication regimen for potential interactions and contraindications.
#### Tapering Off Clonazepam
– Reduce the dose by 0.25 mg every 1-2 weeks.
– Monitor for withdrawal symptoms and adjust the tapering schedule accordingly.
#### Education on Withdrawal Symptoms
– **Common Symptoms**: Anxiety, insomnia, and irritability.
– **Serious Symptoms**: Seizures, confusion, and hallucinations.
### Conclusion
Deprescribing requires a careful, patient-centered approach. It is essential to educate patients about the risks and benefits, provide a structured tapering plan, and monitor for withdrawal symptoms. By using evidence-based guidelines, healthcare providers can ensure safe and effective deprescribing, ultimately improving patient outcomes.
### References
1. Reeve, E., & Gnjidic, D. (2015). Benefits of Deprescribing on Patients’ Health Outcomes: An Updated Systematic Review and Meta-Analysis. *British Journal of Clinical Pharmacology, 80*(6), 1252-1268.
2. Kouladjian O’Donnell, L., et al. (2016). Deprescribing: An Approach to Reducing Polypharmacy in the Elderly. *Journal of Clinical Pharmacy and Therapeutics, 41*(2), 141-151.
3. Voshaar, R. C., et al. (2021). Tapering Strategies for Long-Term Benzodiazepine Use in Adults. *Cochrane Database of Systematic Reviews, 2021*(8), CD009145.
4. Davies, S. J., & Read, C. (2019). Deprescribing Benzodiazepines in Older Patients: Challenges and Strategies. *Therapeutic Advances in Drug Safety, 10*, 2042098619875143.
5. Kalapatapu, R. K., & Sullivan, M. A. (2010). Challenges in Prescribing Benzodiazepines to Older Adults: The Need for More Clinical Trials. *Journal of Clinical Psychiatry, 71*(4), 567-568.
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