Read on Twitter
It's time, Twitter! Our very first case and the topic is: Deprescribing!!
@TomRadomskiMD @PittIMChiefs @MedEdPGH @RawalRachna
@TomRadomskiMD @PittIMChiefs @MedEdPGH @RawalRachna
1/ You patient is an 89yoM w/ COPD, HTN, DM manages his own meds: ASA, statin, cranberry suppl., metformin, lisinopril, HCTZ, lasix, omeprazole, albuterol, tiotropium
What do you think of the list?”
What do you think of the list?”
2/ That's 10 medications! Patients >65 and taking 9+ meds, have a 4x greater chance of being hospitalized for an adverse drug reaction 
3/ How often do you discuss deprescribing with your patients? If you do, how do you systematically do through their med lists?
4/ Our patient is pretty excited about cutting back on his meds. One of the challenges is that his sleep cycle is variable, so would prefer taking pills once per day.
5/ One of the tools the VA uses is VIONE. V stands for Vital, life-saving medications. Which of his meds would you consider Vital?
6/ To make it easy, I'll remind you of his med list:
asa 81, statin, cranberry supplement, metformin, lisinopril, HCTZ, furosemide, omeprazole, albuterol, tiotropium. Which can be considered vital? Why?
asa 81, statin, cranberry supplement, metformin, lisinopril, HCTZ, furosemide, omeprazole, albuterol, tiotropium. Which can be considered vital? Why?
7/ Like all things in medicine, many “just depend.” Metformin can be considered vital if his BGLs are on the high side. HCTZ, lisinopril can be consolidated to one pill
8/ "I" is Important for Quality of Life. For our
, a statin may be discontinued or the dose 
. No
history, so may not be indicated!
, a statin may be discontinued or the dose . Nohistory, so may not be indicated!
9/ Moving right along! "O" is for Optional Meds. These can be supplements or OTCs. Any meds you'd like to take a closer look at?
10/ He started taking cranberry because one of his friends started. He’s also never had a 
or stroke, so no indication for aspirin. 
Let's get those off the list!
or stroke, so no indication for aspirin. Let's get those off the list!
11/ Moving on to my favorite category - "N" for Not Indicated (or treatment complete)! Thoughts?
12/ Turns out furosemide was for LE swelling when he was on amlodipine, but wasn’t d/c’d with the amlodipine. Omeprazole was only for 14-days, but got refills for 2 yrs 
13/ Let's talk about prescribing cascades for a moment 
Patient's who get CCBs have 
relative rate of receiving loop diuretics than those who get ACEi/ARBs!!
Patient's who get CCBs have relative rate of receiving loop diuretics than those who get ACEi/ARBs!!
14/ One last pass for “E” – Every Medication Has An Indication.
Looks like we have a final list: Albuterol PRN, Lisinopril, and Tiotropium – meeting our patient’s goals!
Looks like we have a final list: Albuterol PRN, Lisinopril, and Tiotropium – meeting our patient’s goals!
15/ How does this help our patient?
in co-pays
chance in medication interactions
adverse
drug events
adherence
Bonus: only takes about 20 minutes to go through!
in co-pays chance in medication interactions adverse drug events adherence Bonus: only takes about 20 minutes to go through!
16/ Check out http://deprescribing.org , STEADI-Rx to help with decreasing risk of falls in patients older than 65.
Don't forget to ask your local pharmacist for help!!
Which resources do you use?
Don't forget to ask your local pharmacist for help!!
Which resources do you use?
17/ Thank you to @TomRadomskiMD @CaseyMcQuadeMD and @GaetanSgro for peer-reviewing this tweetorial!
References: Savage et al. [Eval] of a Common Prescribing Cascade of [CCBs] and Diuretics in Adults With [HTN]. JAMA Intern Med. 2020;180(5) and @TomRadomskiMD's work
References: Savage et al. [Eval] of a Common Prescribing Cascade of [CCBs] and Diuretics in Adults With [HTN]. JAMA Intern Med. 2020;180(5) and @TomRadomskiMD's work
