The Journal of Family Practice

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed urticaria pigmentosa. If urticaria pigmentosa is suspected, it is helpful to stroke the lesion with a fingernail or the wooden end of a cotton-tipped applicator. This induces erythema and a wheal that is confined to the stroked site within the lesion—a positive Darier sign.

Urticaria pigmentosa is a form of mast cell activation syndrome (MCAS), in which there are too many mast cells in the skin. More serious forms of MCAS in adults include systemic mastocytosis and cutaneous mastocytosis. Urticaria pigmentosa is a self-limiting problem in young children that rarely causes sufficient symptoms to warrant treatment.

In this case, the FP assured the mother that this was not dangerous and would go away over time on its own. The FP wrote down the name of the condition for the mother and explained to her that if she noticed any changes or new symptoms, she should return for further evaluation and treatment. The mother was satisfied with this explanation.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Urticaria and angioedema. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 863-870.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed urticaria pigmentosa. If urticaria pigmentosa is suspected, it is helpful to stroke the lesion with a fingernail or the wooden end of a cotton-tipped applicator. This induces erythema and a wheal that is confined to the stroked site within the lesion—a positive Darier sign.

Urticaria pigmentosa is a form of mast cell activation syndrome (MCAS), in which there are too many mast cells in the skin. More serious forms of MCAS in adults include systemic mastocytosis and cutaneous mastocytosis. Urticaria pigmentosa is a self-limiting problem in young children that rarely causes sufficient symptoms to warrant treatment.

In this case, the FP assured the mother that this was not dangerous and would go away over time on its own. The FP wrote down the name of the condition for the mother and explained to her that if she noticed any changes or new symptoms, she should return for further evaluation and treatment. The mother was satisfied with this explanation.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Urticaria and angioedema. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 863-870.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed urticaria pigmentosa. If urticaria pigmentosa is suspected, it is helpful to stroke the lesion with a fingernail or the wooden end of a cotton-tipped applicator. This induces erythema and a wheal that is confined to the stroked site within the lesion—a positive Darier sign.

Urticaria pigmentosa is a form of mast cell activation syndrome (MCAS), in which there are too many mast cells in the skin. More serious forms of MCAS in adults include systemic mastocytosis and cutaneous mastocytosis. Urticaria pigmentosa is a self-limiting problem in young children that rarely causes sufficient symptoms to warrant treatment.

In this case, the FP assured the mother that this was not dangerous and would go away over time on its own. The FP wrote down the name of the condition for the mother and explained to her that if she noticed any changes or new symptoms, she should return for further evaluation and treatment. The mother was satisfied with this explanation.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Urticaria and angioedema. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 863-870.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Taking into consideration the patient’s 2 predisposing risk factors (AIDS and dementia), the FP diagnosed seborrheic dermatitis. The FP also noted seborrheic dermatitis on the scalp. The scalp is frequently involved in cases of seborrheic dermatitis on the face.

Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Its presentation may vary from mild erythema to greasy scale, and rarely, to erythroderma. Patients with seborrheic dermatitis may be colonized with certain species of lipophilic yeast of the genus Malassezia (also known as Pityrosporum). Malassezia, however, is considered normal skin flora because it is also found in unaffected people.

Some evidence suggests that an overgrowth of Malassezia may produce different irritants or metabolites on affected skin, leading to inflammation. It’s postulated that an overgrowth of Malassezia leads to the inflammatory dermatitis in seborrhea.

The goals of treatment are to diminish the fungal overgrowth and treat the inflammatory response. Thus, the mainstay of treatment is ongoing topical antifungals in shampoos and other preparations, along with a topical steroid to treat the inflammation.

The FP prescribed 2% ketoconazole shampoo to be used twice weekly and suggested that a selenium-containing shampoo be used on the other days of the week, as well as a 2.5% hydrocortisone cream to be applied twice daily to the face until the dermatitis resolved. The FP also prescribed a topical antifungal, cyclopirox 1% cream, to be applied twice daily on an ongoing basis to keep the Malassezia under control. At a one-month follow-up, the patient’s skin and scalp were cleared.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hancock M, Bae Y, Usatine R. Seborrheic dermatitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 871-877.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

CASE An 82-year-old woman with a history of hypertension, diabetes, hyperlipidemia, stage 3 chronic kidney disease, anxiety, urge urinary incontinence, constipation, and bilateral knee osteoarthritis presents to her primary care physician’s office after a fall. She reports that she visited the emergency department (ED) a week ago after falling in the middle of the night on her way to the bathroom. This is the third fall she’s had this year. On chart review, she had a blood pressure (BP) of 112/60 mm Hg and a blood glucose level of 65 mg/dL in the ED. All other testing (head imaging, chest x-ray, urinalysis) was normal. The ED physician recommended that she stop taking her lisinopril-hydrochlorothiazide (HCTZ) and glipizide extended release (XL) until her follow-up appointment. Today, she asks about the need to restart these medications.

Polypharmacy is common among older adults due to a high prevalence of chronic conditions that often require multiple medications for optimal management. Cut points of 5 or 9 medications are frequently used to define polypharmacy. However, some define polypharmacy as taking a medication that lacks an indication, is ineffective, or is duplicating treatment provided by another medication.

Either way, polypharmacy is associated with multiple negative consequences, including an increased risk for adverse drug events (ADEs),^1-4 drug-drug and drug-disease interactions (TABLE 1^5,6),⁷ reduced functional capacity,⁸ multiple geriatric syndromes (TABLE 2^5,9-12), medication non-adherence,¹³ and increased mortality.¹⁴ Polypharmacy also contributes to increased health care costs for both the patient and the health care system.¹⁵

Taking a step back. Polypharmacy often results from prescribing cascades, which occur when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom. Potentially inappropriate medications (PIMs), which are medications that should be avoided in older adults and in those with certain conditions, are also more likely to be prescribed in the setting of polypharmacy.¹⁶

Deprescribing is the process of identifying and discontinuing medications that are unnecessary, ineffective, and/or inappropriate in order to reduce polypharmacy and improve health outcomes. Deprescribing is a collaborative process that involves weighing the benefits and harms of medications in the context of a patient’s care goals, current level of functioning, life expectancy, values, and preferences. This article reviews polypharmacy and discusses safe and effective deprescribing strategies for older adults in the primary care setting.

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How many people on how many meds?

Polypharmacy often occurs when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom.According to a 2016 study, 36% of community-dwelling older adults (ages 62-85 years) were taking 5 or more prescription medications in 2010 to 2011—up from 31% in 2005 to 2006.¹⁷ When one narrows the population to older adults in the United States who are hospitalized, almost half (46%) take 7 or more medications.¹⁸ Among frail, older US veterans at hospital discharge, 40% were prescribed 9 or more medications, with 44% of these patients receiving at least one unnecessary drug.¹⁹

The challenges of multimorbidity

In the United States, 80% of those 65 and older have 2 or more chronic conditions, or multimorbidity.²⁰ Clinical practice guidelines making recommendations for the management of single conditions, such as heart failure, hypertension, or diabetes, often suggest the use of 2 or more medications to achieve optimal management and fail to provide guidance in the setting of multimorbidity. Following treatment recommendations for multiple conditions predictably leads to polypharmacy, with complicated, costly, and burdensome regimens.

Further, the research contributing to the development of clinical practice guidelines frequently excludes older adults and those with multimorbidity, reducing applicability in this population. As a result, many treatment recommendations have uncertain benefit and may be harmful in the multimorbid older patient.²¹

CASE In addition to the patient’s multimorbidity, she had a stroke at age 73 and has some mild residual left-sided weakness. Functionally, she is independent and able to perform her activities of daily living and her instrumental activities of daily living. She lives alone, quit smoking at age 65, and has an occasional glass of wine during family parties. The patient’s daughter and granddaughter live 2 blocks away.

The goal of deprescribing is to reduce polypharmacy and improve health outcomes.

Her current medications include glipizide XL 10 mg/d and lisinopril-HCTZ 20-25 mg/d, which she has temporarily discontinued at the ED doctor’s recommendation, as well as: amlodipine 10 mg/d, metformin 1000 mg BID, senna 8.6 mg/d, docusate 100 mg BID, furosemide 40 mg/d, and ibuprofen 600 mg/d (for knee pain). She reports taking omeprazole 20 mg/d “for almost 20 years,” even though she has not had any reflux symptoms in recent memory. After her stroke, she began taking atorvastatin 10 mg/d, aspirin 81 mg/d, and clopidogrel 75 mg/d, which she continues to take today. About a year ago, she started oxybutynin 5 mg/d for urinary incontinence, but she has not noticed significant relief. Additionally, she takes lorazepam 1 mg for insomnia most nights of the week.

IMAGE: ©BRIAN STAUFER 2017

A review of systems reveals issues with chronic constipation and intermittent dizziness, but is otherwise negative. The physical examination reveals a well-appearing woman with a body mass index of 26. Her temperature is 98.5° F, her heart rate is 78 beats/min and regular, her respirations are 14 breaths/min, and her BP is 117/65 mm Hg. Orthostatic testing is negative. Her heart, lung, and abdominal exams are within normal limits. Her timed up and go test is 14 seconds. Her blood glucose level today in the office after eating breakfast 2 hours ago is 135 mg/dL (normal: <140 mg/dL). Laboratory tests performed at the time of the ED visit show a creatinine level of 1.2 mg/dL (normal range: 0.6 to 1.1 mg/dL), a glomerular filtration rate (GFR) of 44 units (normal range: >60 units), a hemoglobin level of 9.8 g/dL (normal range: 12-15.5 g/dL), and a thyroid stimulating hormone level of 1.4 mIU/L (normal range: 0.5-8.9 mIU/L). A recent hemoglobin A1C is 6.8% (normal: <5.7%), low-density lipoprotein (LDL) level is 103 mg/dL (optimal <100 mg/dL), and high-density lipoprotein (HDL) level is 65 mg/dL (optimal >60 mg/dL). An echocardiogram performed a year ago showed mild aortic stenosis with normal systolic and diastolic function.

Starting the deprescribing process: Several approaches to choose from

The goal of deprescribing is to reduce polypharmacy and improve health outcomes. It is a process defined as, “reviewing all current medications; identifying medications to be ceased, substituted, or reduced; planning a deprescribing regimen in partnership with the patient; and frequently reviewing and supporting the patient.”²² A medication review should include prescription, over-the-counter (OTC), and complementary/­alternative medicine (CAM) agents.

More than one-third of US men and women ages 62 to 85 years are taking 5 or more prescription medications.Until recently, studies evaluating the process of deprescribing across drug classes and disease conditions were limited, but new research is beginning to show its potential impact. After deprescribing, patients experience fewer falls and show improvements in cognition.²³ While there have not yet been large randomized trials to evaluate deprescribing, a recent systematic review and meta-analysis showed that use of patient-specific deprescribing interventions is associated with improved survival.²⁴ Importantly, there have been no reported adverse drug withdrawal events or deaths associated with deprescribing.²³

Smaller studies have reported additional benefits including decreases in health care costs, reductions in drug-drug interactions and PIMs, improvements in medication adherence, and increases in patient satisfaction.²⁵ In addition, the removal of unnecessary medications may allow for increased consideration of prescribing appropriate medications with known benefit.²⁵

Practically speaking, every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications. Electronic alert systems at pharmacies and those embedded within electronic health record (EHR) systems can also prompt a medication review and an effort to deprescribe.²⁶ Evidence-based tools to identify polypharm­acy and guide appropriate medication use are listed in TABLE 3.^5,6,27-30 In addition, suggested approaches to beginning the deprescribing process are included in TABLE 4.^5,31-33 And a medication class-based approach to deprescribing is provided in TABLE 5.^5,34-45

Although no gold standard process exists for deprescribing, experts suggest that any deprescribing protocol should include the following steps:^32,46

1. Start with a “brown bag” review of the patient’s medications.

Have the patient bring all of his/her medications in a bag to the visit; review them together or have the medication history taken by a pharmacist. Determine and discuss the indication for each medication and its effectiveness for that indication. Consider the potential benefits and harms of each medication in the context of the patient’s care goals and preferences. Assess whether the patient is taking all of the medications that have been prescribed, and identify any reasons for missed pills (eg, adverse effects, dosing regimens, understanding, cognitive issues).

2. Talk to the patient about the deprescribing process.

Talk with the patient about the risks and benefits of deprescribing, and prioritize which medications to address in the process. Prioritize the medications by balancing patient preferences with available pharmacologic evidence. If there is a lack of evidence supporting the benefits for a particular medication, consider known or suspected adverse effects, the ease or burden of the dosing regimen, the patient’s preferences and goals of care, remaining life expectancy, the time until drug benefit is appreciated, and the length of drug benefit after discontinuation.

3. Deprescribe medications.

If you are going to taper a medication, develop a schedule in partnership with the patient. Stop one medication at a time so that you can monitor for withdrawal symptoms or for the return of a condition.

Acknowledging potential barriers to deprescribing may help structure conversations and provide anticipatory guidance to patients and their families. Working to overcome these barriers will help maximize the benefits of deprescribing and help to build trust with patients.

Patient-driven barriers include fear of a condition worsening or returning, lack of a suitable alternative, lack of ongoing support to manage a particular condition, a previous bad experience with medication cessation, and influence from other care providers (eg, family, home caregivers, nurses, specialists, friends). Patients and family members sometimes cling to the hope of future effectiveness of a treatment, especially in the case of medications like donepezil for dementia.⁴⁷ Utilizing a team-based and stepwise patient approach to deprescribing aims to provide hesitant patients with appropriate amounts of education and support to begin to reduce unnecessary medicines.

Provider-driven barriers include feeling uneasy about contradicting a specialist’s recommendations for initiation/continuation of specific medications, fear of causing withdrawal symptoms or disease relapse, and lack of specific data to adequately understand and assess benefits and harms in the older adult population. Primary care physicians have also acknowledged worry about discussing life expectancy and that patients will feel their care is being reduced or “downgraded.”⁴⁸ Finally, there is limited time in which these complex shared decision-making conversations can take place. Thus, if medications are not causing a noticeable problem, it is often easier to just continue them.

Every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications.

One way to overcome some of these concerns is to consider working with a clinical pharmacist. By gaining information regarding medication-specific factors, such as half-life and expected withdrawal patterns, you can feel more confident deprescribing or continuing medications.

Additionally, communicating closely with specialists, ideally with the help of an integra­ted EHR, can allow you to discuss indications for particular medications or concerns about adverse effects, limited benefits, or difficulty with compliance, so that you can develop a collaborative, cohesive, and patient-centered plan. This, in turn, may improve patient understanding and compliance.

4. Create a follow-up plan.

At the time of deprescribing a medication, develop a plan with the patient for monitoring and assessment. Ensure that the patient understands which symptoms may occur in the event of drug withdrawal and which symptoms may suggest the return of a condition. Make sure that other supports are in place if needed (eg, cognitive behavioral therapy, physical therapy, social support or assistance) to help ensure that medication cessation is successful.

CASE During the office visit, you advise the patient that her BP looks normal, her blood sugar is within an appropriate range, and she is lucky to have not sustained any injuries after her most recent fall. In addition to discussing the benefits of some outpatient physical therapy to help with her balance, you ask if she would like to discuss reducing her medications. She is agreeable and asks for your recommendations.

You are aware of several resources that can help you with your recommendations, among them the STOPP/START⁶ and Beers criteria,⁵ as well as the Good Geriatric-Palliative Algorithm.³⁰

If you were to use the STOPP/START and Beers criteria, you might consider stopping:

• lorazepam, which increases the risk of falls and confusion.
• ibuprofen, since this patient has only mild osteoarthritis pain, and ibuprofen has the potential for renal, cardiac, and gastrointestinal toxicities.
• oxybutynin, because it could be contributing to the patient’s constipation and cause confusion and falls.
• furosemide, since the patient has no clinical heart failure.
• omeprazole, since the indication is unknown and the patient has no history of ulceration, esophagitis, or symptomatic gastroesophageal reflux disease.

After reviewing the Good Geriatric-Palliative Algorithm,³⁰ you might consider stopping:

• clopidogrel, as there is no clear indication for this medication in combination with aspirin in this patient.
• glipizide XL, as this patient’s A1c is below goal and this medication puts her at risk of hypoglycemia and its associated morbidities.
• metformin, as it increases her risk of lactic acidosis because her GFR is <45 units.
• docusate, as the evidence to show clear benefit in improving chronic constipation in older adults is lacking.

There have been no reported adverse drug withdrawal events or deaths associated with deprescribing.

You tell your patient that there are multiple medications to consider stopping. In order to monitor any symptoms of withdrawal or return of a condition, it would be best to stop one at a time and follow-up closely. Since she has done well for the past week without the glipizide and lisinopril-HCTZ combination, she can remain off the glipizide and the HCTZ. Lisinopril, however, may provide renal protection in the setting of diabetes and will be continued at this time.

You ask her about adverse effects from her other medications. She indicates that the furosemide makes her run to the bathroom all the time, so she would like to try stopping it. You agree and make a plan for her to monitor her weight, watch for edema, and return in 4 weeks for a follow-up visit.

On follow-up, she is feeling well, has no edema on exam, and is happy to report her urinary incontinence has resolved. You therefore suggest her next deprescribing trial be discontinuation of her oxybutynin. She thanks you for your recommendations about her medications and heads off to her physical therapy appointment.

CORRESPONDENCE
Kathryn McGrath, MD, Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University, 2422 S Broad St, 2nd Floor, Philadelphia, PA 19145; [email protected].

CASE An 82-year-old woman with a history of hypertension, diabetes, hyperlipidemia, stage 3 chronic kidney disease, anxiety, urge urinary incontinence, constipation, and bilateral knee osteoarthritis presents to her primary care physician’s office after a fall. She reports that she visited the emergency department (ED) a week ago after falling in the middle of the night on her way to the bathroom. This is the third fall she’s had this year. On chart review, she had a blood pressure (BP) of 112/60 mm Hg and a blood glucose level of 65 mg/dL in the ED. All other testing (head imaging, chest x-ray, urinalysis) was normal. The ED physician recommended that she stop taking her lisinopril-hydrochlorothiazide (HCTZ) and glipizide extended release (XL) until her follow-up appointment. Today, she asks about the need to restart these medications.

Polypharmacy is common among older adults due to a high prevalence of chronic conditions that often require multiple medications for optimal management. Cut points of 5 or 9 medications are frequently used to define polypharmacy. However, some define polypharmacy as taking a medication that lacks an indication, is ineffective, or is duplicating treatment provided by another medication.

Either way, polypharmacy is associated with multiple negative consequences, including an increased risk for adverse drug events (ADEs),^1-4 drug-drug and drug-disease interactions (TABLE 1^5,6),⁷ reduced functional capacity,⁸ multiple geriatric syndromes (TABLE 2^5,9-12), medication non-adherence,¹³ and increased mortality.¹⁴ Polypharmacy also contributes to increased health care costs for both the patient and the health care system.¹⁵

Taking a step back. Polypharmacy often results from prescribing cascades, which occur when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom. Potentially inappropriate medications (PIMs), which are medications that should be avoided in older adults and in those with certain conditions, are also more likely to be prescribed in the setting of polypharmacy.¹⁶

Deprescribing is the process of identifying and discontinuing medications that are unnecessary, ineffective, and/or inappropriate in order to reduce polypharmacy and improve health outcomes. Deprescribing is a collaborative process that involves weighing the benefits and harms of medications in the context of a patient’s care goals, current level of functioning, life expectancy, values, and preferences. This article reviews polypharmacy and discusses safe and effective deprescribing strategies for older adults in the primary care setting.

[polldaddy:9781245]

How many people on how many meds?

Polypharmacy often occurs when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom.According to a 2016 study, 36% of community-dwelling older adults (ages 62-85 years) were taking 5 or more prescription medications in 2010 to 2011—up from 31% in 2005 to 2006.¹⁷ When one narrows the population to older adults in the United States who are hospitalized, almost half (46%) take 7 or more medications.¹⁸ Among frail, older US veterans at hospital discharge, 40% were prescribed 9 or more medications, with 44% of these patients receiving at least one unnecessary drug.¹⁹

The challenges of multimorbidity

In the United States, 80% of those 65 and older have 2 or more chronic conditions, or multimorbidity.²⁰ Clinical practice guidelines making recommendations for the management of single conditions, such as heart failure, hypertension, or diabetes, often suggest the use of 2 or more medications to achieve optimal management and fail to provide guidance in the setting of multimorbidity. Following treatment recommendations for multiple conditions predictably leads to polypharmacy, with complicated, costly, and burdensome regimens.

Further, the research contributing to the development of clinical practice guidelines frequently excludes older adults and those with multimorbidity, reducing applicability in this population. As a result, many treatment recommendations have uncertain benefit and may be harmful in the multimorbid older patient.²¹

CASE In addition to the patient’s multimorbidity, she had a stroke at age 73 and has some mild residual left-sided weakness. Functionally, she is independent and able to perform her activities of daily living and her instrumental activities of daily living. She lives alone, quit smoking at age 65, and has an occasional glass of wine during family parties. The patient’s daughter and granddaughter live 2 blocks away.

The goal of deprescribing is to reduce polypharmacy and improve health outcomes.

Her current medications include glipizide XL 10 mg/d and lisinopril-HCTZ 20-25 mg/d, which she has temporarily discontinued at the ED doctor’s recommendation, as well as: amlodipine 10 mg/d, metformin 1000 mg BID, senna 8.6 mg/d, docusate 100 mg BID, furosemide 40 mg/d, and ibuprofen 600 mg/d (for knee pain). She reports taking omeprazole 20 mg/d “for almost 20 years,” even though she has not had any reflux symptoms in recent memory. After her stroke, she began taking atorvastatin 10 mg/d, aspirin 81 mg/d, and clopidogrel 75 mg/d, which she continues to take today. About a year ago, she started oxybutynin 5 mg/d for urinary incontinence, but she has not noticed significant relief. Additionally, she takes lorazepam 1 mg for insomnia most nights of the week.

IMAGE: ©BRIAN STAUFER 2017

A review of systems reveals issues with chronic constipation and intermittent dizziness, but is otherwise negative. The physical examination reveals a well-appearing woman with a body mass index of 26. Her temperature is 98.5° F, her heart rate is 78 beats/min and regular, her respirations are 14 breaths/min, and her BP is 117/65 mm Hg. Orthostatic testing is negative. Her heart, lung, and abdominal exams are within normal limits. Her timed up and go test is 14 seconds. Her blood glucose level today in the office after eating breakfast 2 hours ago is 135 mg/dL (normal: <140 mg/dL). Laboratory tests performed at the time of the ED visit show a creatinine level of 1.2 mg/dL (normal range: 0.6 to 1.1 mg/dL), a glomerular filtration rate (GFR) of 44 units (normal range: >60 units), a hemoglobin level of 9.8 g/dL (normal range: 12-15.5 g/dL), and a thyroid stimulating hormone level of 1.4 mIU/L (normal range: 0.5-8.9 mIU/L). A recent hemoglobin A1C is 6.8% (normal: <5.7%), low-density lipoprotein (LDL) level is 103 mg/dL (optimal <100 mg/dL), and high-density lipoprotein (HDL) level is 65 mg/dL (optimal >60 mg/dL). An echocardiogram performed a year ago showed mild aortic stenosis with normal systolic and diastolic function.

Starting the deprescribing process: Several approaches to choose from

The goal of deprescribing is to reduce polypharmacy and improve health outcomes. It is a process defined as, “reviewing all current medications; identifying medications to be ceased, substituted, or reduced; planning a deprescribing regimen in partnership with the patient; and frequently reviewing and supporting the patient.”²² A medication review should include prescription, over-the-counter (OTC), and complementary/­alternative medicine (CAM) agents.

More than one-third of US men and women ages 62 to 85 years are taking 5 or more prescription medications.Until recently, studies evaluating the process of deprescribing across drug classes and disease conditions were limited, but new research is beginning to show its potential impact. After deprescribing, patients experience fewer falls and show improvements in cognition.²³ While there have not yet been large randomized trials to evaluate deprescribing, a recent systematic review and meta-analysis showed that use of patient-specific deprescribing interventions is associated with improved survival.²⁴ Importantly, there have been no reported adverse drug withdrawal events or deaths associated with deprescribing.²³

Smaller studies have reported additional benefits including decreases in health care costs, reductions in drug-drug interactions and PIMs, improvements in medication adherence, and increases in patient satisfaction.²⁵ In addition, the removal of unnecessary medications may allow for increased consideration of prescribing appropriate medications with known benefit.²⁵

Practically speaking, every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications. Electronic alert systems at pharmacies and those embedded within electronic health record (EHR) systems can also prompt a medication review and an effort to deprescribe.²⁶ Evidence-based tools to identify polypharm­acy and guide appropriate medication use are listed in TABLE 3.^5,6,27-30 In addition, suggested approaches to beginning the deprescribing process are included in TABLE 4.^5,31-33 And a medication class-based approach to deprescribing is provided in TABLE 5.^5,34-45

Although no gold standard process exists for deprescribing, experts suggest that any deprescribing protocol should include the following steps:^32,46

1. Start with a “brown bag” review of the patient’s medications.

Have the patient bring all of his/her medications in a bag to the visit; review them together or have the medication history taken by a pharmacist. Determine and discuss the indication for each medication and its effectiveness for that indication. Consider the potential benefits and harms of each medication in the context of the patient’s care goals and preferences. Assess whether the patient is taking all of the medications that have been prescribed, and identify any reasons for missed pills (eg, adverse effects, dosing regimens, understanding, cognitive issues).

2. Talk to the patient about the deprescribing process.

Talk with the patient about the risks and benefits of deprescribing, and prioritize which medications to address in the process. Prioritize the medications by balancing patient preferences with available pharmacologic evidence. If there is a lack of evidence supporting the benefits for a particular medication, consider known or suspected adverse effects, the ease or burden of the dosing regimen, the patient’s preferences and goals of care, remaining life expectancy, the time until drug benefit is appreciated, and the length of drug benefit after discontinuation.

3. Deprescribe medications.

If you are going to taper a medication, develop a schedule in partnership with the patient. Stop one medication at a time so that you can monitor for withdrawal symptoms or for the return of a condition.

Acknowledging potential barriers to deprescribing may help structure conversations and provide anticipatory guidance to patients and their families. Working to overcome these barriers will help maximize the benefits of deprescribing and help to build trust with patients.

Patient-driven barriers include fear of a condition worsening or returning, lack of a suitable alternative, lack of ongoing support to manage a particular condition, a previous bad experience with medication cessation, and influence from other care providers (eg, family, home caregivers, nurses, specialists, friends). Patients and family members sometimes cling to the hope of future effectiveness of a treatment, especially in the case of medications like donepezil for dementia.⁴⁷ Utilizing a team-based and stepwise patient approach to deprescribing aims to provide hesitant patients with appropriate amounts of education and support to begin to reduce unnecessary medicines.

Provider-driven barriers include feeling uneasy about contradicting a specialist’s recommendations for initiation/continuation of specific medications, fear of causing withdrawal symptoms or disease relapse, and lack of specific data to adequately understand and assess benefits and harms in the older adult population. Primary care physicians have also acknowledged worry about discussing life expectancy and that patients will feel their care is being reduced or “downgraded.”⁴⁸ Finally, there is limited time in which these complex shared decision-making conversations can take place. Thus, if medications are not causing a noticeable problem, it is often easier to just continue them.

Every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications.

One way to overcome some of these concerns is to consider working with a clinical pharmacist. By gaining information regarding medication-specific factors, such as half-life and expected withdrawal patterns, you can feel more confident deprescribing or continuing medications.

Additionally, communicating closely with specialists, ideally with the help of an integra­ted EHR, can allow you to discuss indications for particular medications or concerns about adverse effects, limited benefits, or difficulty with compliance, so that you can develop a collaborative, cohesive, and patient-centered plan. This, in turn, may improve patient understanding and compliance.

4. Create a follow-up plan.

At the time of deprescribing a medication, develop a plan with the patient for monitoring and assessment. Ensure that the patient understands which symptoms may occur in the event of drug withdrawal and which symptoms may suggest the return of a condition. Make sure that other supports are in place if needed (eg, cognitive behavioral therapy, physical therapy, social support or assistance) to help ensure that medication cessation is successful.

CASE During the office visit, you advise the patient that her BP looks normal, her blood sugar is within an appropriate range, and she is lucky to have not sustained any injuries after her most recent fall. In addition to discussing the benefits of some outpatient physical therapy to help with her balance, you ask if she would like to discuss reducing her medications. She is agreeable and asks for your recommendations.

You are aware of several resources that can help you with your recommendations, among them the STOPP/START⁶ and Beers criteria,⁵ as well as the Good Geriatric-Palliative Algorithm.³⁰

If you were to use the STOPP/START and Beers criteria, you might consider stopping:

• lorazepam, which increases the risk of falls and confusion.
• ibuprofen, since this patient has only mild osteoarthritis pain, and ibuprofen has the potential for renal, cardiac, and gastrointestinal toxicities.
• oxybutynin, because it could be contributing to the patient’s constipation and cause confusion and falls.
• furosemide, since the patient has no clinical heart failure.
• omeprazole, since the indication is unknown and the patient has no history of ulceration, esophagitis, or symptomatic gastroesophageal reflux disease.

After reviewing the Good Geriatric-Palliative Algorithm,³⁰ you might consider stopping:

• clopidogrel, as there is no clear indication for this medication in combination with aspirin in this patient.
• glipizide XL, as this patient’s A1c is below goal and this medication puts her at risk of hypoglycemia and its associated morbidities.
• metformin, as it increases her risk of lactic acidosis because her GFR is <45 units.
• docusate, as the evidence to show clear benefit in improving chronic constipation in older adults is lacking.

There have been no reported adverse drug withdrawal events or deaths associated with deprescribing.

You tell your patient that there are multiple medications to consider stopping. In order to monitor any symptoms of withdrawal or return of a condition, it would be best to stop one at a time and follow-up closely. Since she has done well for the past week without the glipizide and lisinopril-HCTZ combination, she can remain off the glipizide and the HCTZ. Lisinopril, however, may provide renal protection in the setting of diabetes and will be continued at this time.

You ask her about adverse effects from her other medications. She indicates that the furosemide makes her run to the bathroom all the time, so she would like to try stopping it. You agree and make a plan for her to monitor her weight, watch for edema, and return in 4 weeks for a follow-up visit.

On follow-up, she is feeling well, has no edema on exam, and is happy to report her urinary incontinence has resolved. You therefore suggest her next deprescribing trial be discontinuation of her oxybutynin. She thanks you for your recommendations about her medications and heads off to her physical therapy appointment.

CORRESPONDENCE
Kathryn McGrath, MD, Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University, 2422 S Broad St, 2nd Floor, Philadelphia, PA 19145; [email protected].

CASE An 82-year-old woman with a history of hypertension, diabetes, hyperlipidemia, stage 3 chronic kidney disease, anxiety, urge urinary incontinence, constipation, and bilateral knee osteoarthritis presents to her primary care physician’s office after a fall. She reports that she visited the emergency department (ED) a week ago after falling in the middle of the night on her way to the bathroom. This is the third fall she’s had this year. On chart review, she had a blood pressure (BP) of 112/60 mm Hg and a blood glucose level of 65 mg/dL in the ED. All other testing (head imaging, chest x-ray, urinalysis) was normal. The ED physician recommended that she stop taking her lisinopril-hydrochlorothiazide (HCTZ) and glipizide extended release (XL) until her follow-up appointment. Today, she asks about the need to restart these medications.

Polypharmacy is common among older adults due to a high prevalence of chronic conditions that often require multiple medications for optimal management. Cut points of 5 or 9 medications are frequently used to define polypharmacy. However, some define polypharmacy as taking a medication that lacks an indication, is ineffective, or is duplicating treatment provided by another medication.

Either way, polypharmacy is associated with multiple negative consequences, including an increased risk for adverse drug events (ADEs),^1-4 drug-drug and drug-disease interactions (TABLE 1^5,6),⁷ reduced functional capacity,⁸ multiple geriatric syndromes (TABLE 2^5,9-12), medication non-adherence,¹³ and increased mortality.¹⁴ Polypharmacy also contributes to increased health care costs for both the patient and the health care system.¹⁵

Taking a step back. Polypharmacy often results from prescribing cascades, which occur when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom. Potentially inappropriate medications (PIMs), which are medications that should be avoided in older adults and in those with certain conditions, are also more likely to be prescribed in the setting of polypharmacy.¹⁶

Deprescribing is the process of identifying and discontinuing medications that are unnecessary, ineffective, and/or inappropriate in order to reduce polypharmacy and improve health outcomes. Deprescribing is a collaborative process that involves weighing the benefits and harms of medications in the context of a patient’s care goals, current level of functioning, life expectancy, values, and preferences. This article reviews polypharmacy and discusses safe and effective deprescribing strategies for older adults in the primary care setting.

[polldaddy:9781245]

How many people on how many meds?

Polypharmacy often occurs when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom.According to a 2016 study, 36% of community-dwelling older adults (ages 62-85 years) were taking 5 or more prescription medications in 2010 to 2011—up from 31% in 2005 to 2006.¹⁷ When one narrows the population to older adults in the United States who are hospitalized, almost half (46%) take 7 or more medications.¹⁸ Among frail, older US veterans at hospital discharge, 40% were prescribed 9 or more medications, with 44% of these patients receiving at least one unnecessary drug.¹⁹

The challenges of multimorbidity

In the United States, 80% of those 65 and older have 2 or more chronic conditions, or multimorbidity.²⁰ Clinical practice guidelines making recommendations for the management of single conditions, such as heart failure, hypertension, or diabetes, often suggest the use of 2 or more medications to achieve optimal management and fail to provide guidance in the setting of multimorbidity. Following treatment recommendations for multiple conditions predictably leads to polypharmacy, with complicated, costly, and burdensome regimens.

Further, the research contributing to the development of clinical practice guidelines frequently excludes older adults and those with multimorbidity, reducing applicability in this population. As a result, many treatment recommendations have uncertain benefit and may be harmful in the multimorbid older patient.²¹

CASE In addition to the patient’s multimorbidity, she had a stroke at age 73 and has some mild residual left-sided weakness. Functionally, she is independent and able to perform her activities of daily living and her instrumental activities of daily living. She lives alone, quit smoking at age 65, and has an occasional glass of wine during family parties. The patient’s daughter and granddaughter live 2 blocks away.

The goal of deprescribing is to reduce polypharmacy and improve health outcomes.

Her current medications include glipizide XL 10 mg/d and lisinopril-HCTZ 20-25 mg/d, which she has temporarily discontinued at the ED doctor’s recommendation, as well as: amlodipine 10 mg/d, metformin 1000 mg BID, senna 8.6 mg/d, docusate 100 mg BID, furosemide 40 mg/d, and ibuprofen 600 mg/d (for knee pain). She reports taking omeprazole 20 mg/d “for almost 20 years,” even though she has not had any reflux symptoms in recent memory. After her stroke, she began taking atorvastatin 10 mg/d, aspirin 81 mg/d, and clopidogrel 75 mg/d, which she continues to take today. About a year ago, she started oxybutynin 5 mg/d for urinary incontinence, but she has not noticed significant relief. Additionally, she takes lorazepam 1 mg for insomnia most nights of the week.

IMAGE: ©BRIAN STAUFER 2017

A review of systems reveals issues with chronic constipation and intermittent dizziness, but is otherwise negative. The physical examination reveals a well-appearing woman with a body mass index of 26. Her temperature is 98.5° F, her heart rate is 78 beats/min and regular, her respirations are 14 breaths/min, and her BP is 117/65 mm Hg. Orthostatic testing is negative. Her heart, lung, and abdominal exams are within normal limits. Her timed up and go test is 14 seconds. Her blood glucose level today in the office after eating breakfast 2 hours ago is 135 mg/dL (normal: <140 mg/dL). Laboratory tests performed at the time of the ED visit show a creatinine level of 1.2 mg/dL (normal range: 0.6 to 1.1 mg/dL), a glomerular filtration rate (GFR) of 44 units (normal range: >60 units), a hemoglobin level of 9.8 g/dL (normal range: 12-15.5 g/dL), and a thyroid stimulating hormone level of 1.4 mIU/L (normal range: 0.5-8.9 mIU/L). A recent hemoglobin A1C is 6.8% (normal: <5.7%), low-density lipoprotein (LDL) level is 103 mg/dL (optimal <100 mg/dL), and high-density lipoprotein (HDL) level is 65 mg/dL (optimal >60 mg/dL). An echocardiogram performed a year ago showed mild aortic stenosis with normal systolic and diastolic function.

Starting the deprescribing process: Several approaches to choose from

The goal of deprescribing is to reduce polypharmacy and improve health outcomes. It is a process defined as, “reviewing all current medications; identifying medications to be ceased, substituted, or reduced; planning a deprescribing regimen in partnership with the patient; and frequently reviewing and supporting the patient.”²² A medication review should include prescription, over-the-counter (OTC), and complementary/­alternative medicine (CAM) agents.

More than one-third of US men and women ages 62 to 85 years are taking 5 or more prescription medications.Until recently, studies evaluating the process of deprescribing across drug classes and disease conditions were limited, but new research is beginning to show its potential impact. After deprescribing, patients experience fewer falls and show improvements in cognition.²³ While there have not yet been large randomized trials to evaluate deprescribing, a recent systematic review and meta-analysis showed that use of patient-specific deprescribing interventions is associated with improved survival.²⁴ Importantly, there have been no reported adverse drug withdrawal events or deaths associated with deprescribing.²³

Smaller studies have reported additional benefits including decreases in health care costs, reductions in drug-drug interactions and PIMs, improvements in medication adherence, and increases in patient satisfaction.²⁵ In addition, the removal of unnecessary medications may allow for increased consideration of prescribing appropriate medications with known benefit.²⁵

Practically speaking, every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications. Electronic alert systems at pharmacies and those embedded within electronic health record (EHR) systems can also prompt a medication review and an effort to deprescribe.²⁶ Evidence-based tools to identify polypharm­acy and guide appropriate medication use are listed in TABLE 3.^5,6,27-30 In addition, suggested approaches to beginning the deprescribing process are included in TABLE 4.^5,31-33 And a medication class-based approach to deprescribing is provided in TABLE 5.^5,34-45

Although no gold standard process exists for deprescribing, experts suggest that any deprescribing protocol should include the following steps:^32,46

1. Start with a “brown bag” review of the patient’s medications.

Have the patient bring all of his/her medications in a bag to the visit; review them together or have the medication history taken by a pharmacist. Determine and discuss the indication for each medication and its effectiveness for that indication. Consider the potential benefits and harms of each medication in the context of the patient’s care goals and preferences. Assess whether the patient is taking all of the medications that have been prescribed, and identify any reasons for missed pills (eg, adverse effects, dosing regimens, understanding, cognitive issues).

2. Talk to the patient about the deprescribing process.

Talk with the patient about the risks and benefits of deprescribing, and prioritize which medications to address in the process. Prioritize the medications by balancing patient preferences with available pharmacologic evidence. If there is a lack of evidence supporting the benefits for a particular medication, consider known or suspected adverse effects, the ease or burden of the dosing regimen, the patient’s preferences and goals of care, remaining life expectancy, the time until drug benefit is appreciated, and the length of drug benefit after discontinuation.

3. Deprescribe medications.

If you are going to taper a medication, develop a schedule in partnership with the patient. Stop one medication at a time so that you can monitor for withdrawal symptoms or for the return of a condition.

Acknowledging potential barriers to deprescribing may help structure conversations and provide anticipatory guidance to patients and their families. Working to overcome these barriers will help maximize the benefits of deprescribing and help to build trust with patients.

Patient-driven barriers include fear of a condition worsening or returning, lack of a suitable alternative, lack of ongoing support to manage a particular condition, a previous bad experience with medication cessation, and influence from other care providers (eg, family, home caregivers, nurses, specialists, friends). Patients and family members sometimes cling to the hope of future effectiveness of a treatment, especially in the case of medications like donepezil for dementia.⁴⁷ Utilizing a team-based and stepwise patient approach to deprescribing aims to provide hesitant patients with appropriate amounts of education and support to begin to reduce unnecessary medicines.

Provider-driven barriers include feeling uneasy about contradicting a specialist’s recommendations for initiation/continuation of specific medications, fear of causing withdrawal symptoms or disease relapse, and lack of specific data to adequately understand and assess benefits and harms in the older adult population. Primary care physicians have also acknowledged worry about discussing life expectancy and that patients will feel their care is being reduced or “downgraded.”⁴⁸ Finally, there is limited time in which these complex shared decision-making conversations can take place. Thus, if medications are not causing a noticeable problem, it is often easier to just continue them.

Every encounter between a patient and health care provider is an opportunity to reduce unnecessary medications.

One way to overcome some of these concerns is to consider working with a clinical pharmacist. By gaining information regarding medication-specific factors, such as half-life and expected withdrawal patterns, you can feel more confident deprescribing or continuing medications.

Additionally, communicating closely with specialists, ideally with the help of an integra­ted EHR, can allow you to discuss indications for particular medications or concerns about adverse effects, limited benefits, or difficulty with compliance, so that you can develop a collaborative, cohesive, and patient-centered plan. This, in turn, may improve patient understanding and compliance.

4. Create a follow-up plan.

At the time of deprescribing a medication, develop a plan with the patient for monitoring and assessment. Ensure that the patient understands which symptoms may occur in the event of drug withdrawal and which symptoms may suggest the return of a condition. Make sure that other supports are in place if needed (eg, cognitive behavioral therapy, physical therapy, social support or assistance) to help ensure that medication cessation is successful.

CASE During the office visit, you advise the patient that her BP looks normal, her blood sugar is within an appropriate range, and she is lucky to have not sustained any injuries after her most recent fall. In addition to discussing the benefits of some outpatient physical therapy to help with her balance, you ask if she would like to discuss reducing her medications. She is agreeable and asks for your recommendations.

You are aware of several resources that can help you with your recommendations, among them the STOPP/START⁶ and Beers criteria,⁵ as well as the Good Geriatric-Palliative Algorithm.³⁰

If you were to use the STOPP/START and Beers criteria, you might consider stopping:

• lorazepam, which increases the risk of falls and confusion.
• ibuprofen, since this patient has only mild osteoarthritis pain, and ibuprofen has the potential for renal, cardiac, and gastrointestinal toxicities.
• oxybutynin, because it could be contributing to the patient’s constipation and cause confusion and falls.
• furosemide, since the patient has no clinical heart failure.
• omeprazole, since the indication is unknown and the patient has no history of ulceration, esophagitis, or symptomatic gastroesophageal reflux disease.

After reviewing the Good Geriatric-Palliative Algorithm,³⁰ you might consider stopping:

• clopidogrel, as there is no clear indication for this medication in combination with aspirin in this patient.
• glipizide XL, as this patient’s A1c is below goal and this medication puts her at risk of hypoglycemia and its associated morbidities.
• metformin, as it increases her risk of lactic acidosis because her GFR is <45 units.
• docusate, as the evidence to show clear benefit in improving chronic constipation in older adults is lacking.

There have been no reported adverse drug withdrawal events or deaths associated with deprescribing.

You tell your patient that there are multiple medications to consider stopping. In order to monitor any symptoms of withdrawal or return of a condition, it would be best to stop one at a time and follow-up closely. Since she has done well for the past week without the glipizide and lisinopril-HCTZ combination, she can remain off the glipizide and the HCTZ. Lisinopril, however, may provide renal protection in the setting of diabetes and will be continued at this time.

You ask her about adverse effects from her other medications. She indicates that the furosemide makes her run to the bathroom all the time, so she would like to try stopping it. You agree and make a plan for her to monitor her weight, watch for edema, and return in 4 weeks for a follow-up visit.

On follow-up, she is feeling well, has no edema on exam, and is happy to report her urinary incontinence has resolved. You therefore suggest her next deprescribing trial be discontinuation of her oxybutynin. She thanks you for your recommendations about her medications and heads off to her physical therapy appointment.

CORRESPONDENCE
Kathryn McGrath, MD, Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University, 2422 S Broad St, 2nd Floor, Philadelphia, PA 19145; [email protected].

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

EVIDENCE SUMMARY

A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE^1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.

Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.¹ Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.

The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.¹

A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.²

Neurodevelopmental effects on infants, long-term effects on children, teens

Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.^1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).

The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.^1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.

The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.^1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).

The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.

Marijuana potency has increased substantially since the 1980s, when many of the studies were done. (THC content was 3.2% in 1983 and 13% in 2008.)

The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.^1,3,4 The final assessment included only 51 children.

RECOMMENDATIONS

The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.⁹ Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.

ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.

The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.¹⁰

EVIDENCE SUMMARY

A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE^1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.

Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.¹ Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.

The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.¹

A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.²

Neurodevelopmental effects on infants, long-term effects on children, teens

Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.^1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).

The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.^1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.

The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.^1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).

The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.

Marijuana potency has increased substantially since the 1980s, when many of the studies were done. (THC content was 3.2% in 1983 and 13% in 2008.)

The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.^1,3,4 The final assessment included only 51 children.

RECOMMENDATIONS

The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.⁹ Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.

ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.

The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.¹⁰

EVIDENCE SUMMARY

A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE^1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.

Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.¹ Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.

The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.¹

A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.²

Neurodevelopmental effects on infants, long-term effects on children, teens

Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.^1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).

The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.^1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.

The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.^1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).

The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.

Marijuana potency has increased substantially since the 1980s, when many of the studies were done. (THC content was 3.2% in 1983 and 13% in 2008.)

The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.^1,3,4 The final assessment included only 51 children.

RECOMMENDATIONS

The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.⁹ Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.

ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.

The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.¹⁰

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.