The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials.

Background Polypharmacy is common among older people and may be associated with adverse drug events (ADEs) and poor health outcomes. Pharmacists are well-positioned to reduce polypharmacy and potentially inappropriate medications. Objective The objective of this narrative review was to summarize the results from randomized-controlled trials that evaluated pharmacist-led interventions with the goal or effect to deprescribe medications in older individuals. Data Sources We searched Medline, Embase, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. Data Synthesis Of the 25 studies included, the interventions were conducted in nursing facilities (n = 8), outpatient/community dwellings (n = 8), or community pharmacies (n = 9). Interventions were categorized as comprehensive medication reviews (n = 10), comprehensive medication reviews with pharmacist follow-up (n = 11), and educational interventions provided to patients and/or providers (n = 4). Pharmacist-led interventions had a beneficial effect on 22 out of 32 total medication-related outcomes (eg, number of medications, potentially inappropriate medications, or discontinuation). Most (n = 18) studies reported no evidence of an effect for other outcomes such as health care use, mortality, patient-centered outcomes (falls, cognition, function, quality of life), and ADEs. Discussion Interventions led to improvement in 69% of the medication-related outcomes examined across study settings. Five studies measured ADEs with none accounting for adverse drug-withdrawal events. Large well-designed studies that are powered to find an effect on patient-centered outcomes are needed. Conclusion Pharmacist-led interventions had a significant beneficial effect on medication-related outcomes. There was little evidence of benefit on other outcomes.

ASCP's 2021 Choosing Wisely® Recommendations: A Proud Accomplishment.

Choosing Wisely® (CW) is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments, and procedures. The campaign began in the United States in 2012 and in Canada in 2014, and now many countries around the world are adapting the campaign and implementing it. Currently, approximately 80 societies in the United States have published CW recommendations. Each recommendation is supported by clinical guidelines (when necessary), evidence-based ratinale, including information about when these tests or procedures may be appropriate. A deprescribing task force led by Chair Beier was created by ASCP in November 2018 after several conversations between ASCP leadership (notably, President J. Hirshfield) and Beier. Task force members comprise pharmacists practicing in academia, community, and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and scientific literature base. One of the primary goals for Chair Beier was to add ASCP's voice to the ABIM CW Campaign. Because ASCP is a membership association that represents pharmacists, health care professionals, and students serving the unique medication needs of older patients, by adding its name to the list of supporting partners, the organization makes a compelling argument to address deprescribing initiatives, tools, scientific literature, and resources to assist in initiating deprescribing conversations and their subsequent implementation.

Vigilance of Drug-Drug interactions to Mitigate ADRs: Front and Center for Pharmacists.

As the number of people taking multiple medications increases, differing approaches to address drug-drug interactions and adverse drug reactions have been debated-but not solved-despite excellent criteria to stop the use of potentially inappropriate medications.

Pharmacogenetics: has the time come for pharmacists to embrace and implement the science?

Pharmacogenetics--the study of interindividual differences in medication response as a result of genetic variations--has emerged as a potentially useful tool for individualizing medication regimens for patients. Genetic variations can affect drug disposition inseveral ways, from modifying receptor sensitivities to impacting drug metabolism. Over the last several years, the Food and Drug Administration has been steadily including pharmacogenetic information in drug labeling for several commonly prescribed drugs. Several organizations are attempting to provide evidence-based guidelines for widespread implementation and interpretation. Pharmacists, armed with knowledge of drug metabolism pathways and drug-gene interactions, are uniquely positioned to play an active role in the education, provision, and clinical implementation of pharmacogenetics.

Treatment strategies for the behavioral symptoms of Alzheimer's disease: focus on early pharmacologic intervention.

The impact of behavioral symptoms associated with Alzheimer's disease is substantial. These symptoms contribute to diminished quality of life for patients and caregivers and increase the cost of care in nursing homes. Early recognition of behavioral symptoms and appropriate treatment are important for successful management. Nonpharmacologic strategies remain the cornerstone of the management of Alzheimer's disease-related behavioral symptoms. However, nonpharmacologic strategies may not be effective for problem behaviors, and pharmacologic intervention may be necessary. Relevant articles were identified through various MEDLINE searches with no date restrictions, with an emphasis on recent studies that used cholinesterase inhibitors and memantine. Additional reports of interest were identified from the reference lists of these articles. To facilitate cross-study analyses in the review of cholinesterase inhibitors and memantine, the database search was limited to randomized, placebo-controlled trials that used the Neuropsychiatric Inventory to assess behavioral symptoms of Alzheimer's disease. Overall, evidence from trials of cholinesterase inhibitors and memantine suggests that when these agents are optimized for the various stages of Alzheimer's disease, they can also prevent the emergence of neuropsychiatric symptoms. Although results from the literature are not uniformly positive, cholinesterase inhibitors have been shown to produce significant improvements in behavioral symptoms in patients with both mild- to-moderate and moderate-to-severe Alzheimer's disease. Evidence also indicates that memantine might be of benefit as an adjunct to long-term cholinesterase inhibitor treatment in patients with moderate-to-severe Alzheimer's disease and that memantine monotherapy may have some beneficial effects on behavior in patients with mild-to-moderate disease. Of importance, although no direct comparisons have been performed, these agents seem to have an improved safety and tolerability profile compared with the frequently used antipsychotic drugs. When nonpharmacologic strategies are deemed insufficient to ease problem behaviors in patients with Alzheimer's disease, treatment with cholinesterase inhibitors, alone or in combination with memantine as appropriate for the stage of disease, may be considered as a first-line option in the early pharmacologic management of Alzheimer's disease-related behavioral symptoms.

Pharmacotherapy for behavioral and psychological symptoms of dementia in the elderly.

PURPOSE: The use of atypical antipsychotics for maximizing clinical efficacy and overall health in patients with neuropsychiatric symptoms of dementia is discussed. SUMMARY: Psychotic and behavioral symptoms are common among older patients with dementia, and an accurate diagnosis can be obscured by complex presentation of symptoms and comorbidities. When initiating pharmacotherapy in this patient population, it is important to consider the increased presence of comorbidities and the additive pharmacologic effects of concomitantly administered drugs. Atypical antipsychotics are among the most well-studied therapeutic classes of psychoactive medications and are frequently utilized for treating psychotic symptoms and agitation in the elderly. These medications have distinct pharmacologic profiles with different liabilities for adverse effects such as sedation, metabolic disturbances, and anticholinergic effects. Recent findings from the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD) study demonstrate that although these agents have some efficacy, their adverse effects may limit their utility in patients. CONCLUSION: The adverse effect profile should be an important consideration for clinicians selecting an atypical antipsychotic for use in this population.

Gradual dose reduction and medication tapering: a clinical perspective.

Recent changes in the State Operations Manual put new emphasis on attempts to gradually reduce the dose of certain medications -- namely psychotropic medications -- as a component of medication management in nursing facilities. Applying these federal guidelines to caring for elderly patients is often highly complex. It requires an understanding of existing clinical evidence, the current standards of practice for using these medications, and the appropriate rationale for attempting to reduce drug dosages.

Pharmacotherapy of behavioral and psychological symptoms of dementia: a review of atypical antipsychotics.

OBJECTIVE: To review the literature on use of antipsychotics to treat behavioral and psychological symptoms of dementia (BPSD). DATA SOURCES: Information was selected from a MEDLINE search of English-language medical literature using the search terms "antipsychotics" and "elderly." Manual searches of pertinent journal article references, and review of poster presentations at recent professional meetings were also performed. STUDY SELECTION: Meta-analyses published in 1990 and 1998 were used as a starting point for information about conventional antipsychotics. Articles reporting the results of controlled trials of conventional antipsychotics published since the second meta-analysis (October 1998) were included. Also included were articles reporting the results of controlled clinical trials of atypical antipsychotics (i.e., clozapine, risperidone, olanzapine, quetiapine, ziprasidone) for the treatment of dementia in the elderly. Studies and post hoc analyses of special patient populations (Parkinson's disease, schizophrenia, treatment-refractory BPSD) were excluded. One open-label extension and one post hoc analysis were included because they provide valuable information about the long-term use of atypical antipsychotics. One poster was included, as it contained the only data available from a controlled trial of quetiapine. DATA EXTRACTION: Data were extracted from the literature, as well as a recent scientific poster presentation. Two meta-analyses and six controlled studies were identified for inclusion. DATA SYNTHESIS: There are few controlled clinical trials of the use of antipsychotics in elderly patients with dementia. Currently available information indicates these medications are useful in the treatment of behavioral and psychological symptoms of dementia, but the clinician must exercise caution because of the drugs' potential side effects. CONCLUSION: While widely prescribed on an "off-label" basis, there is a dearth of placebo-controlled clinical trials necessary to evaluate safety, and head-to-head comparative studies necessary to contrast efficacy and safety of atypical antipsychotics in treating BPSD.