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.
## Importance of De-prescribing
De-prescribing is the process of tapering or stopping medications that may no longer be beneficial or may be causing harm. It is essential for optimizing patient care, particularly in populations such as the elderly, those on multiple medications, and individuals with chronic conditions. De-prescribing helps reduce the risk of adverse drug reactions, drug interactions, and medication burden, ultimately improving patient outcomes and quality of life.
### Patient 1: 36-Year-Old Male on Opioid Analgesic and Clonazepam
#### Concerns of Remaining on Both Medications
– **Risks of Opioids and Benzodiazepines:** Combining opioid analgesics with benzodiazepines increases the risk of respiratory depression, sedation, and overdose. Both medications are central nervous system depressants and can exacerbate these effects when taken together.
– **Dependence and Withdrawal:** Long-term use of both opioids and benzodiazepines can lead to physical dependence, making it difficult to discontinue them without experiencing withdrawal symptoms.
#### Patient Education
– **Risks of Continued Use:** Educate the patient about the increased risk of respiratory depression, sedation, and potential overdose when using these medications in combination. Discuss the potential for dependence and withdrawal symptoms.
– **Benefits of Tapering Off Clonazepam:** Explain how tapering off clonazepam can reduce these risks and improve overall health. Emphasize that this process will be managed carefully to minimize withdrawal symptoms and maintain mental health stability.
#### Tapering Off Clonazepam
– **Tapering Schedule:** Suggest a gradual tapering schedule, such as reducing the dose by 0.25 mg every 2-4 weeks, to minimize withdrawal symptoms. Monitor the patient closely for signs of withdrawal or recurrence of panic attacks.
– **New Medication for Panic Attacks:** Consider prescribing an SSRI (Selective Serotonin Reuptake Inhibitor) such as sertraline or fluoxetine, which are effective for panic disorder and have a lower risk of dependence.
– **Initiating the New Medication:** Start the SSRI at a low dose, such as sertraline 25 mg daily, and gradually increase it to the therapeutic dose. Monitor the patient for side effects and effectiveness.
#### Legal, Ethical, or Social Consideration
– **Informed Consent:** Ensure the patient is fully informed about the risks and benefits of de-prescribing and the new treatment plan. Obtain informed consent, emphasizing the importance of following the tapering schedule and attending follow-up appointments.
### Patient 2: 42-Year-Old Female on Alprazolam
#### Withdrawal Symptoms from Alprazolam
– **Common Withdrawal Symptoms:** Anxiety, insomnia, restlessness, and mild tremors.
– **Serious Withdrawal Symptoms:** Seizures, severe agitation, hallucinations, and confusion. These symptoms warrant immediate medical attention.
#### Patient Education
– **Common Withdrawal Symptoms:** Explain that anxiety, insomnia, and mild tremors are common but manageable. Provide strategies to cope with these symptoms, such as relaxation techniques and sleep hygiene.
– **Serious Withdrawal Symptoms:** Emphasize the importance of seeking medical attention if experiencing severe agitation, hallucinations, or seizures.
#### Transition to Longer-Acting Benzodiazepine
– **Choosing a Benzodiazepine:** Diazepam is a suitable option due to its longer half-life, which allows for a smoother tapering process.
– **Tapering Schedule:** Convert alprazolam 1 mg BID to diazepam 10 mg BID, then gradually reduce the diazepam dose by 2 mg every 1-2 weeks, depending on the patient’s response.
### Patient 3: 24-Year-Old Pregnant Female on Lorazepam
#### Risks, Benefits, and Side Effects of Continuing Lorazepam
– **Risks to Fetus:** Lorazepam crosses the placenta and may cause fetal sedation, withdrawal symptoms, and potential teratogenic effects.
– **Benefits to Mother:** Effective management of anxiety symptoms, which can otherwise negatively impact pregnancy.
– **Potential Side Effects:** Drowsiness, dizziness, and dependence.
#### Alternative Medications for Generalized Anxiety Disorder
– **SSRIs:** Such as sertraline and fluoxetine, are considered safer during pregnancy. They have a lower risk of congenital malformations and are effective for anxiety.
– **Risks and Benefits:** SSRIs may cause mild side effects such as nausea and headache but are generally safer for the developing fetus.
#### Discontinuing Lorazepam
– **Tapering Schedule:** Recommend reducing the lorazepam dose by 0.25 mg every 1-2 weeks. Monitor for withdrawal symptoms and provide support.
– **Potential Side Effects:** Common side effects include mild anxiety and insomnia; serious side effects such as severe agitation or seizures require medical attention.
#### Risks of Untreated Anxiety During Pregnancy
– **Maternal Risks:** Increased risk of preeclampsia, poor self-care, and postpartum depression.
– **Fetal Risks:** Premature birth, low birth weight, and developmental issues.
### Patient 4: 71-Year-Old Male on Clonazepam
#### Risks of Benzodiazepines in the Elderly
– **Side Effects:** Increased risk of falls, cognitive impairment, and sedation.
– **Evaluation:** Assess the patient’s cognitive function and risk of falls through clinical assessments and family reports.
#### Tapering Off Clonazepam
– **Tapering Schedule:** Suggest reducing the clonazepam dose by 0.25 mg every 2-4 weeks. Monitor for withdrawal symptoms and cognitive function.
– **Potential Withdrawal Symptoms:** Common symptoms include anxiety and insomnia; severe symptoms such as seizures require immediate medical attention.
### Conclusion
De-prescribing requires careful consideration of the patient’s clinical history, current health status, and potential withdrawal symptoms. Providing patient education, a structured tapering schedule, and alternative treatment options are crucial for successful de-prescribing. Collaboration with the patient and their family ensures a comprehensive approach to optimizing medication management.
### References
1. Bjerregaard, P., & Young, T. K. (2018). The circumpolar Inuit: health of a population in transition. *International Journal of Circumpolar Health*, 77(1), 1428353. https://doi.org/10.1080/22423982.2018.1428353
2. Egeland, G. M., et al. (2011). Sugars and risk factors for obesity and diabetes among Inuit in Nunavut: Baseline results from the Healthy Foods North project. *Journal of Human Nutrition and Dietetics*, 24(1), 35-45. https://doi.org/10.1111/j.1365-277X.2010.01129.x
3. Flores, G. (2016). Language barriers in healthcare: a global snapshot. *Global Health Action*, 9(1), 31282. https://doi.org/10.3402/gha.v9.31282
4. Graham, J., et al. (2018). Cross-cultural communication in healthcare: A literature review. *Patient Education and Counseling*, 101(6), 1184-1196. https://doi.org/10.1016/j.pec.2018.01.004
5. Grigoryev, D. (2019). Cross-cultural differences in personal space: An empirical comparison between Russia and the United States. *Journal of Cross-Cultural Psychology*, 50(6), 736-751. https://doi.org/10.1177/0022022119843731
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