Spring 2018 Provider Communicator Newsletter
This is a newsletter article. The information may not be up-to-date. If you have questions, please contact your Provider Coordinator.

The Push to Desprescribe

Polypharmacy is defined as taking five or more medications daily.  It is not surprising that one survey1 found more than 50 percent of Medicare patients had five daily prescriptions; 12 percent of these patients were prescribed ten or more medications. 

It is essential that every opportunity is taken to reduce the number of medications prescribed to a single patient. A review of medications can help avoid unnecessary side effects, negative drug interactions and wasted money.  Below are some medications that may warrant careful analysis of the benefits and risks before continuing to click the refill button on your prescribing software.

Proton Pump Inhibitors (PPIs)4

Evidence is accumulating that indicates the long-term use of PPIs is not as safe as many assume.  Chronic use of these acid-suppressing medications has been implicated in reduced absorption of calcium (leading to fractures), Vitamin B12, and thyroid hormone, as well as increased risk of Clostridium difficile infection and acute and chronic kidney infection.  While some patients do require long-term use of PPIs, they are not indicated for many patients who have been using them for years (i.e., GERD, started as stress ulcer prophylaxis while hospitalized, etc).  When no longer indicated, PPIs should be tapered very slowly over the course of weeks (to prevent rebound reflux) and can be replaced as needed with the use of an H2 receptor-blocker (such as ranitidine, famotidine, or others) or an antacid, such as chewable calcium carbonate.

Antibiotics before Dental Procedures

Even though the guidelines for prevention of endocarditis were changed in 19972, antibiotics continue to be prescribed before dental procedures for patients with prosthetic joints despite there being no evidence to support this practice.  In 2015, the American Dental Association guidelines specifically discourage this practice.3

Benzodiazepines and “Z” Drugs

Benzodiazepines and “Z” Drugs (zolpidem, zaleplon, and eszopiclone) come with a risk of falls, and therefore should be avoided in older adults.4, 5  Some patients may be on multiple medications that can increase the risk of falls, and these effects can potentiate each other, leading to a very real risk of a fall and fracture.

Drugs for Asthma / COPD

In a 2017 study, one-third of adults who had been diagnosed with asthma had normal respiratory tests (spirometry / peak flow) and were successfully weaned off of asthma medications.6 Authors found that not using spirometry to make the original diagnosis was most often the source of the diagnostic error.  Similar rates of misdiagnosis of asthma have been found in other studies as well. 7, 8

Muscle Relaxants for Back Pain

The evidence of benefit is insufficient to recommend the use of muscle relaxants for the treatment of subacute or chronic low back pain.9 These medications cause many adverse effects (especially when combined with alcohol) and can be particularly dangerous in older adults.

Statins for Primary Prevention

There is little evidence that statins are beneficial when prescribed for primary prevention in patients older than age 75.10, 11 Additionally, many statins have well-documented drug interactions, making the risk clearly outweigh the benefits.  While the benefits are well established for secondary prevention, the risks and benefits of continuing a statin for primary prevention in adults over 75 years should be carefully evaluated.

Anticholinesterase Inhibitors for Dementia

This drug class offers modest benefits and sometimes significant side effects. For every patient who receives a modest benefit from this drug, 11 patients receive no benefit. 12 In addition to lack of efficacy, side effects of these medications can include weight loss, nausea, syncope and urinary incontinence. 13, 14

  1. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287:337-344.
  2. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Clin Infect Dis. 1997;25:1448-1458.
  3. Kao FC, Hsu YC, Chen WH, Lin JN, Lo YY, Tu YK. Prosthetic joint infection following invasive dental procedures and antibiotic prophylaxis in patients with hip or knee arthroplasty. Infect Control Hosp Epidemiol. 2017;38:154-161.
  4. Díaz-Gutiérrez MJ, Martínez-Cengotitabengoa M, Sáez de Adana E, et al. Relationship between the use of benzodiazepines and falls in older adults: A systematic review. Maturitas. 2017;101:17-22.
  5. Yu NW, Chen PJ, Tsai HJ, et al. Association of benzodiazepine and Z-drug use with the risk of hospitalisation for fall-related injuries among older people: a nationwide nested case-control study in Taiwan. BMC Geriatr. 2017;17:140.
  6. Aaron SD, Vandemheen KL, FitzGerald JM, et al. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA. 2017;317:269-279.
  7. Heffler E, Pizzimenti S, Guida G, Bucca C, Rolla G. Prevalence of over-/misdiagnosis of asthma in patients referred to an allergy clinic. J Asthma. 2015;52:931-934.
  8. Jain VV, Allison DR, Andrews S, Mejia J, Mills PK, Peterson MW. Misdiagnosis among frequent exacerbators of clinically diagnosed asthma and COPD in absence of confirmation of airflow obstruction. Lung. 2015;193:505-512.
  9. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM, Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976). 2003;28:1978-1992.
  10. Han BH, Sutin D, Williamson JD, et al; ALLHAT Collaborative Research Group. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults: the ALLHAT-LLT randomized clinical trial. JAMA Intern Med. 2017;177:955-965.
  11. Ridker PM, Lonn E, Paynter NP, Glynn R, Yusuf S. Primary prevention with statin therapy in the elderly: new meta-analyses from the contemporary JUPITER and HOPE-3 randomized trials. Circulation. 2017;135:1979-1981.
  12. Kaduszkiewicz H, Zimmermann T, Beck-Bornholdt HP, van den Bussche H. Cholinesterase inhibitors for patients with Alzheimer's disease: systematic review of randomized clinical trials. BMJ. 2005;331:321-327.
  13. Sheffrin M, Miao Y, Boscardin WJ, Steinman MA. Weight loss associated with cholinesterase inhibitors in individuals with dementia in a national healthcare system. J Am Geriatr Soc. 2015;63:1512-1518.
  14. Starr JM. Cholinesterase inhibitor treatment and urinary incontinence in Alzheimer's'disease. J Am Geriatr Soc. 2007;55:800-801.