Polypharmacy and Inappropriate Medication Use in Patients with … · 2018-07-16 · Polypharmacy...
Transcript of Polypharmacy and Inappropriate Medication Use in Patients with … · 2018-07-16 · Polypharmacy...
Polypharmacy and Inappropriate Medication Use in Patients with
Cognitive Impairment
Yeoh Ting Ting Ting Ting Yeoh (Ms)
BSc (Pharmacy), Hons, MSc (Oncology), BCGP, BCOP, BCACP Oncology Specialist Pharmacist
30 June 2018
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Faculty Disclosure
✓ No, nothing to disclose Yes, please specify:
I, Ting Ting Yeoh, have no financial relationship or affiliation to disclose.
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When?
What & How?
Why?
Outline
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The Relationship between Medication-use & Cognitive Impairment in Older cancer patients
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Cancer
Age
Mul-pleComorbidity
&Polypharm
Cogni-veimpairment
(CI)
Riskfactorforcancer
www.cancer.gov/about-cancer/causes-preven2on/risk/ageHolmesHMetal(2008).JAmGeriatrSoc56:1306-1311LangeM.etal(2014).CancerTreatmentReviews40:810-817
AssociatedwithCI
Associatedwith↑comorbidity&polypharmacy
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Cancer
Age
Mul-pleComorbidity
&Polypharm
Cogni-veimpairment
(CI)
Chemotherapy-relatedCogni-veImpairment(CRCI)/
‘Chemobrain’
CIaffectssurvival&adherence
Riskfactor
LibertYetal(2016).PLoSONE11(8):e0159734LohKPetal(2016)JGeriatrOnc7:270-180VitaliMetal(2017).CritRevinOncHematol118:7-14
Associa-on
Associa-on
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Cancer
Age
Mul-pleComorbidity
&Polypharm
Cogni-veimpairment
(CI)
Chemotherapy-relatedCogni-veImpairment(CRCI)/
‘Chemobrain’
CIaffectssurvival&adherence
Ass’dwithpoorercogni-vecapability
Riskfactorforcancer
RiskfactorforCI
EllioWRAetal(2015).CurrClinPharmacol.10:213-221RawlesMJetal(2018):JAmGeriatrSoc.DOI:10.1111/jgs.15317
Pronetonon-adherence
What is polypharmacy?
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Definition of Polypharmacy (Poll)
A. Utilisation of 5 or more medications B. Utilisation of 7 or more medications C. Utilisation of 11 or more medications
D. Utilisation of 2 or more medications for more than 240 days
E. Taking multiple unnecessary medications
Masnoonetal(2017).BMCGeriatrics17:230
138 definitions of Polypharmacy & associated
terms (e.g. minor polypharmacy) have been
identified!
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What can we, as Healthcare Professionals, do?
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Supporting elderly patients
Review appropriateness
Deprescribing Ensure adherence
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Potentially Inappropriate Medications (PIM)
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Examples of tools to identify PIMs in Older Adults
• Beers Criteria for PIM use in Older Adults • STOPP/ START Criteria for Potentially
inappropriate prescribing in older people • Medication Appropriateness Index (MAI) • Others: HEDIS DAE, IPET, Zhan, ACOVE-3
WhitmanA.M.etal(2016)TheOncologist21:723-730
IPET=ImprovingPrescribingintheElderlyToolACOVE-3=AssessingCareofVulnerableElders-3
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Important PIMs in Dementia/ Cognitive Impairment
• Anticholinergics (e.g. certain antidepressants, antiparkinsonians, skeletal muscle relaxants, antipsychotics, antimuscarinics, antispasmodics, antiemetics)
• H2- receptor antagonists (e.g. famotidine, ranitidine)
• Benzodiazepines • Benzodiazepine- receptor agonist hypnotics
(e.g. Zolpidem)
• Antipsychotics for behavioural problems of dementia & delirium (unless non- pharmacological options have failed and the older adult is threatening to harm to self/ others)
Please refer to Holmes HM et al (2008), J Am Geriatr Soc 56: 1306-1311 for a list of PIMs in Advanced Dementia
AmericanGeriatricsSociety(2015)JAmGeriatrSoc.DOI:10.1111/jgs.13702
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De-prescribing
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What is prescribing?
ü diagnose a problem ü make a therapeutic decision ü alter the natural history
ü consider the risk associated with individual drugs
ü consider the cumulative risk from multiple drugs due to pharmacokinetic and pharmacodynamics interactions
ScoWIA.JAMAInternMed2015Mar
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What is prescribing?
ü a positive, patient- centred intervention ü with inherent uncertainties ü requires shared decision making
ü informed patient consent ü and close monitoring of effects
ScoWIA.JAMAInternMed2015Mar
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What is de- prescribing?
ü Diagnose a problem ü Make a therapeutic decision ü Alter the natural history
ü Consider the risk associated with individual drugs
ü Consider the cumulative risk from multiple drugs due to pharmacokinetic and pharmacodynamics interactions
ScoWIA.JAMAInternMed2015Mar
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What is de- prescribing?
ü A positive, patient- centred intervention ü with inherent uncertainties ü requires shared decision making
ü informed patient consent ü and close monitoring of effects
ScoWIA.JAMAInternMed2015Mar
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What is De- prescribing?
De- prescribing is defined as the systematic
process of identifying and discontinuing drugs in instances in which existing or potential
harms outweigh existing or potential benefits within the context of an individual patient’s care goals, current level of functioning, life
expectancy, values, and preferences.
ScoWIA.JAMAInternMed2015Mar
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Published De-prescribing Tools
De-prescribing in general populations: • 5- step de-prescribing tools by Scott et al. De-prescribing in cancer/ end-of-life care: • OncPal de-prescribing tools by Lindsay et al.
ScoWIAetal(2015).JAMAInternMed175(5):827-34LindsayJetal(2015).JSupportCareCancer.23:71-78
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5-Step Deprescribing Process
Performacomprehensivemedica-on-indica-on
reconcilia-on
Consideroverallriskofdrug-induced
harm
Assesseachmedica-onforeligibility
tobediscon-nued
Priori-semedica-onsfordiscon-nua-on
Implementdrugdiscon-nua-on
planandmonitoradverse
withdrawaleffects
Step1 Step2 Step3 Step4 Step5
ScoWIAetal(2015).JAMAInternMed175(5):827-34
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ScoWIAetal(2015).JAMAInternMed175(5):827-34
Steps 3 & 4:
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Step 5: Implement drug discontinuation plan and monitor adverse withdrawal effects
• Monitor for adverse withdrawal reactions or return of symptoms
• Counsel patient/caregiver on steps to take
• Implement non-pharmacological measures
• Document process and outcome, communicate to other healthcare providers
ScoWIAetal(2015).JAMAInternMed175(5):827-34
5-Step Deprescribing Process
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Barriers to de-prescribing
• High- levels of clinical complexity • Limited consultation time • Fragmented care among multiple prescribers • Incomplete information (on past rationales for, and
patient tolerance of, drugs) • Ambiguous or changing care goals • Uncertainty about the benefits & harms of
continuing & discontinuing specific drugs • Community & professional attitudes toward more
rather then less use of drugs • Fear of adverse effects
ScoWIAetal(2015).JAMAInternMed175(5):827-34
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De-prescribing in end-of-life: Continuum of Palliative Cancer Care
FerrisFD(2009)JClinicalOncology.27:3052-58
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2009
2013
2014
2015 2018
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StevensonJ(2004).BMJ.329:999-1012
Table: Factors influencing the likelihood of continuing treatment for medical comorbidities in patients with life- limiting illness
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OncPal De-prescribing Guideline in end- of- life care Medica-on
ClassMedica-on Considera-onsforlimited
benefitExplana-on
Blood Aspirin For1opreven2on Longtermbenefitsatpopula2onlevel.LiWleshortorintermediatetermriskofstopping.Drugsforprimarypreven2onhave,ingeneral,noplaceinthetreatmentofend-of-lifepa2entssince2me-to-benefitusuallyexceedslifeexpectancy
Cardiovascularsystem
Dyslipidaemia-sta2ns,fibrate,eze2mibe
Allindica2ons Long-termbenefitsatpopula2onlevel.LiWleshort/intermediatetermriskofstopping
An-hypertensives
Ifsoleuseistoreducemild-moderatehypertensionfor2opreven2onofCVevents/asmanagementofstableCAD
Long-termbenefitsatpopula2onlevel.Ongoingtherapyunnecessaryinmostshortenedlifeexpectancy
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LindsayJetal(2015).JSupportCareCancer.23:71-78
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OncPal De-prescribing Guideline: It’s Role
• Assist in identifying potentially inappropriate medications (PIMs)
• Aid in rationalization of medications
LindsayJetal(2015).JSupportCareCancer.23:71-78
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Challenges for de- prescribing in end- of- life
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ToddA(2015).IntJClinPharmdoi:10.1007/s11096-015-0148-6KutnerJS(2015).JAMAInternMeddoi:10.1001/jamainternmed.2015.0289StevensonJ(2004).BMJ;329:999-1012
Guidelines applicable to general elderly populations are not directly transferrable
Predicting the time of ‘shift’
General practitioner? Oncologist? Other specialist?
How do you explain end of life to patients?
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Recommendations to support De-prescribing
1. Shared decision- making in prescribing & de- prescribing medications
2. Not prescribing a medication should be presented as a reasonable alternative for patients late in life, when appropriate
3. De- prescribing is a part of prescribing 4. Prescribers have to embrace uncertainty 5. Difficult discussions now will simplify difficult
decisions in the future
ToddA(2015).IntJClinPharmdoi:10.1007/s11096-015-0148-6
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Improving Adherence
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Improving adherence
• Simplifyregimen(reduceno.ofdrugs/frequency)
• Educatepa2ent(importanceofmeds,awarenessofgoals)
• Integratedinterven2ons(regularmedreviews,systemiccoopera2onbetweenphysicians&pharmacists)
• Dataontheuseofaidsiscontroversial
EllioWRAetal(2015).CurrClinPharmacol.10:213-221CostaEetal(2015)PaAentPreferenceandAdherence9:1303–1314Mis2aenPetal(2006)BMCHealthServiceRes.7:47CampbellNLetal(2012)AmJGeriartPharmacother10:165-177
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When?
What & How?
Why?
Regular, ongoing
Decision Tools/ Algorithms + Shared- decision making
Complex interaction among age, cancer, comorbidities & cognitive status calling for individualised
therapies
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References Cancer therapy and Cognitive impairment • Vitali M. et al. (2017) Cognitive impairment and chemotherapy: a brief overview. Current Reviews in
Oncology/ Hematology 118: 7-14 • Given C.W. et al. (2016) Care of the Elderly Patient on Oral Oncolytics for Advanced Disease. Current
Geriatrics Report 5:233- 239 • Libert Y et al. (2016) Vulnerabilities in Older Patients when Cancer Treatment is Initiated: Does a
Cognitive Impairment impact the 2-year survival? PLoS ONE 11(8):e0159734 doi:10.1371/journal/pone.0159734
• Karuturi M. et al. (2016) Understanding cognition in older patients with cancer. Journal of Geriatric Oncology 7: 258-269
• Lange M. et al. Cognitive dysfunctions in elderly cancer patients: A new challenge for oncologists. Cancer Treatment Review 40: 810-817
• Libert Y et al (2016). Vulnerabilities in Older Patients when Cancer Treatment is initiated: Does a cognitive impairment impact the two-year survival? PLoS ONE 11(8): e0159734
• Loh KP et a (2016). Chemotherapy- related cognitive impairment in older patients with cancer. J Geriatr Onc 7: 270-280
Polypharmacy and Cognitive Impairment • Oyarzun-Gonzalez XA et al (2015). Cognitive Decline and Polypharmacy in an elderly population. J Am.
Geriartr Soc 63(2): 397-99 • Rawle MJ e al (2018). Associations between polypharmacy and Cognitive and Physical Capability: A
British Birth Cohort Study. J Am Geriatr Soc DOI: 10.1111/jgs.15317 • Elliott RA et al (2015) Ability of Older person with dementia or cognitive impairment to manage
medicine regiments: A Narrative Review Curr Clin Pharmacol 10:213-221 Polypharmacy/ Potentially inappropriate Medications among Cancer Patients • Goh I, et al. (2018) Prevalence and Risk of Polypharmacy among elderly cancer patients receiving
chemotherapy in ambulatory oncology setting. Current Oncology Report 20:38 • Whitman, A.M. et al (2016) A Comprehensive Look at Polypharmacy and Medication Screening Tools
for older cancer patients. The Oncologist 21: 723-730
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References (continued)
Polypharmacy/ Potentially inappropriate Medications among Older Persons • Rawle M.J. (2018) Association between polypharmacy and cognitive and physical
capability: A British Birth Cohort Study. Journal of American Geriatrics Society doi:10.11111/jgs.15317
De-prescribing • Scott I.A. et al. (2015) Reducing Inappropriate Polypharmacy- The process of
Deprescribing. JAMA Intern Med. 175(5): 827-834 • Akinbolade O. et al. (2016) Deprescribing in Advanced Illness. Progress in Palliative Care
24(5): 268-271 • Kutner J.S. et al. (2015) Safety and Benefit of discontinuing statin therapy in the setting of
advanced, life- limiting illness. 175(5): 691- 700 • Lindsay J. et al. (2014) The development and evaluation of an oncological palliative care
deprescribing guidelines: the “OncPal deprescribing guideline’. Support Care Cancer doi: 10.1007/s00520-014-2322-0
• Stevenson J. et al. (2004) Managing comorbidities in patients at the end of life. BMJ 329: 909-12
• Reeve E. et al. (2016) The Ethics of deprescribing in older adults. Bioethical Inquiry 13: 581-590
Others • Masnoon et al (2017) What is polypharmacy?A systematic review of definitions. BMC
Geriatrics 17:230 • Costa E et al (2015Interventional tools to improve medication adherence: review of
literature Patient Preference and Adherence 9: 1303–1314 • Mistiaen P et al (2006). Interventions aimed at reducing problems in adult patients
discharged from hospital to home: a systematic meta-reviewBMC Health Service Res. 7:47
• Campbell NL et al (2012) Medication Adherence in Older Adults With Cognitive Impairment: A Systematic Evidence-Based Review. Am J Geriart Pharmacother 10:165-177
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Thank you
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About NCCS
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Comprehensive Cancer Care
Joint Tumour Board
Counseling Support
Oncologic Nursing
Palliative Care
Surgical Oncology
Medical Oncology
Radiation Oncology
Oncologic Imaging
Research
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Manpower
CATEGORY ApproxNumber(31Mar2014)
Clinicians 141 Nursing 136
AlliedHealth 173 Research 194
Administra-on/Ancillary
257
Total 901
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Instances when de-prescribing can be considered
ü presenting with a new symptom or clinical syndrome suggestive of ADE;
ü manifesting advanced or end-stage disease, terminal illness, dementia, extreme frailty, or full dependence on others for all care;
ü receiving high-risk drugs or combinations;
ü receiving preventive drugs for scenarios associated with no increased disease risk despite drug cessation
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ScoWIA.JAMAInternMed2015Mar
De- prescribing in End- of- Life
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Case Vignette
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A 68 year old woman with extensive small cell lung cancer & rapid weight loss also has long term mild hypertension with no evidence of end organ damage. What would you do about her antihypertensive treatment? a) Stop drug treatment because she has a terminal illness b) Continue the drugs because you would not want her blood
pressure to get worse (and the conversation about stopping them may be difficult because last year you told her she would be taking these drugs for the rest of her life)
c) Wait until she develops postural hypotension and then consider reducing her drugs
d) Reduce her drugs and watch carefully
StevensonJ.BMJ2004;329:999-1012
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OncPal Deprescribing Guideline (cont’d)
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Medica-onClass
Medica-on Considera-onsforlimitedbenefit
Explana-on
MusculoskeletalSystem
OsteoporosisMedica-ons-bisphosphonates,raloxifene,stron2um,denosumab
Exceptifusedforthetreatmentofhypercalcaemiasecondarytobonemetastases
Longtermbenefitsatpopula2onlevel.LiWleshortorintermediatetermriskofstopping.
Alimentarytractandmetabolism
Pep-culcerprophylaxis-Protonpumpinhibitors,H2antagonists
Lackofanymedicalhistoryofgastrointes2nalbleeding,pep2culcer,gastri2s,GORD/GERD,ortheconcomitantuseofan2-inflammatoryagentsincludingNSAIDsandsteroids
Ongoingtherapyunnecessaryinmostshortenedlifeexpectancy
LindsayJ.JSupportCareCancer2015;23:71-78
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OncPal Deprescribing Guideline (cont’d)
Medica-on Considera-onsforlimitedbenefit Explana-on
OralHypoglycaemics Ifsoleuseistoreducemildhyperglycaemiaforsecondarypreven2onofdiabe2cassociatedevents
Poten2alshort-termcomplica2onsoutweighbenefits
Vitamins,Minerals,Complementary-alterna2vemedicines
Ifnotindicatedtotreatalowbloodplasmaconcentra2on
Noevidenceforeffec2veness
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LindsayJ.JSupportCareCancer2015;23:71-78
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Conceptual Frameworks
Consider factors such as: ü Remaining life- expectancy ü Goals of care
ü Time to benefit (of meds)
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ToddA.IntJClinPharm(2015)doi:10.1007/s11096-015-0148-6HolmesHMetal.ArchInternMed2006;166(6):605-9CurrowDCetal.ArchInternMed2006;166(21):2404GarfinkelDetal.ArchInternMed2010;170(18):1648-54
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Can Artificial Intelligence (AI) solve problems with Polypharmacy/ PIM?
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Potential utilities of AI in De-prescribing
• Risk prediction tools • Clinical decision support tools • Machine/ Deep Learning algorithms • ‘Dr De- prescriber’?
o Ethicalissueso Whathappentoshared-decision
making?
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Research/ Practice Gaps
Future research questions
• Quantitative data on health outcomes from active de- prescribing programs in elderly cancer patients
• Quality of life outcomes from active de- prescribing programs in elderly cancer patients
• Pharmacoeconomic data on the benefits of active de- prescribing programs in elderly cancer patients
• Effectiveness of collaboration between Medical Oncologists, Palliative Care Specialist, Geriatrician, Family Physicians and Pharmacists
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Step 1: Perform a comprehensive medication-indication reconciliation
• Include prescription and non-prescription drugs
• Document indication for each drug • Identify ADRs and non-compliance
ScoWIAetal(2015).JAMAInternMed175(5):827-34
5-Step Deprescribing Process
• Drug factors o Number of drugs
o History of toxicity/ADRs
o Use tools e.g. BEERS list, STOPP criteria
• Patient factors
o Age (>80y)
o Cognitive impairment o Multiple comorbidities o Multiple prescribers
ScoWIAetal(2015).JAMAInternMed175(5):827-34
5-Step Deprescribing Process
Step 2: Consider overall risk of drug-induced harm
Step 3: Assess each medication for eligibility to be discontinued
• Jointly consider life expectancy and treatment goals
• Identify medications used for o Unconfirmed diagnosis
o Confirmed diagnosis but no evidence for choice of treatment
o Counteracting ADR of other medications
ScoWIAetal(2015).JAMAInternMed175(5):827-34
5-Step Deprescribing Process
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Step 4: Prioritise medications for discontinuation • Discontinue medication with greatest harm and least
benefit first
• Taper dose of medications that cause withdrawal symptoms
• Ensure patient/caregiver is comfortable with decision
• Discontinue one at a time
ScoWIAetal(2015).JAMAInternMed175(5):827-34
5-Step Deprescribing Process
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To stop or not to stop?
ü Pharmacokinetics/ dynamics of drugs ü Prognosis ü Pathophysiology of death
ü Measure of benefit ü Aims of intervention ü Psychological concerns
StevensonJ(2004).BMJ.329:999-1012
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OncPal De-prescribing Guideline: Limitations
• Steps to de- prescribe including planning the medication withdrawal (tapering, if required), monitoring and follow up after cessation not included
• Risks associated with withdrawal of medications, including potential stress to patients & carers, and potential adverse drug withdrawal reactions not addressed
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LindsayJetal(2015).JSupportCareCancer.23:71-78ReeveE(2014).JSupportCareCancer;doi:10.1007/s00520-014-2445-3
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Ethical Issues in de-prescribing: Principlism Approach
Beneficence
Non-maleficence
Autonomy
Jus2ce
Reeve,E.etal(2016).BioethicalInquiry13:581-590