Prof. Doron GarfinkelHomecare Hospice Israel Cancer Association, Israel
Title: Rational deprescribing – The best way to reduce polypharmacy
Background: The increase in life expectancy and age related diseases is associated with rapid increase in vulnerable subpopulations of very old, those with co-morbidity, Dementia, Frailty and limited life expectancy (VOCODFLEX). Being treated by increased number of specialists, each prescribing medication from their field, this eventually created the first iatrogenic epidemic of inappropriate medication use and polypharmacy (IMUP) with its huge negative medical and economic consequences. Furthermore, for most medications there are no EBM studies/guidelines in older people and VOCODFLEX and they are all treated based on guidelines proven in much younger, healthier populations. The decrease in the benefit/risk ratio for all medications is age related and becomes most significant in end of life patients (1).
Objectives: To evaluate in older people with polypharmacy, whether the beneficial effect of reducing IMUP by Poly-de-prescribing (PDP) on Quality of life (QoL) and several clinical outcomes outweighs the sum total of all negative outcomes resulting from discontinuation of combinations of the specific drugs.
Methods: In all studies the Garfinkel Palliative-Geriatric method and algorithm (GPGP) were used in older people with polypharmacy consuming at Least 6 prescription drugs. Following thorough explanations & discussions with the patient/family and with their consent, de-prescribing of as many "Non-life saving" drugs as possible is performed with strict follow up sometimes for many years evaluating changes in objective & subjective clinical outcomes, QoL and general satisfaction from PDP.
Results: The first study was performed in disabled patients in 6 nursing departments. After one year out of 331 drugs de-prescribed, only 32 (10%) were re-administered. As compared to the control group who had continued medications "as usual", annual mortality and severe complications requiring referral to acute care facility were significantly reduced in PDP (p < 0.002 in both) (2). The preliminary study in community dwelling older people was published in Arch Int. Med in 2010 (3), De-prescribing was recommended for 311 medications in 64 patients (58% of drugs, 4.4 ± 2.5 drugs per patient overall). Of the de-prescribed drugs, 2% were restarted because of recurrence of original indication, successful discontinuation achieved in 81% with no significant adverse events or deaths attributed to PDP, and 88% reported global improvement in health. The next longitudinal studies were performed in several hundred older people with follow up of 3 – 10 years. As compared to those who de-prescribed less than 2 drugs, in older people who performed PDP, there was a statistically significant improvement in functional and cognitive status, sleep quality, appetite, serious complications, QoL and general satisfaction from PDP intervention. The rate of hospitalizations and mortality were comparable. The clinical improvement caused by PDP was evident usually within 3 months and persisted for several years. Anothe longitudinal study also showed that the number of medications de-prescribed correlated to the extent of improvement. Refusal of the family
Doron Garfinkel graduated school of medicine at Tel Aviv University in 1973. Specializations in internal medicine, palliative medicine, and geriatrics; 2-year fellowship, clinical pharmacology, Stanford university medical center, California. Previously head of a Geriatric-Palliative department at the Shoham geriatric center, in Israel, currently deputy head of the Homecare Hospice of the Israel Cancer Association, and Head, of the center for appropriate medication use, Sheba medical center in Israel (ranked among the 10 best hospitals in the world by Newsweek). Main clinical and research activities concentrate on age-associated diseases & end of life topics, original research on sleep disorders and controlled release of melatonin, and SEVERAL STUDIES on rational deprescribing. In his longitudinal studies, Prof. Garfinkel has proven that rational massive deprescribing is associated with longstanding improvement in quality of life and clinical outcomes including functional, mental, and cognitive status, and is both efficacious and safe. In 2013, Prof. Garfinkel has founded IGRIMUP - International Group for Reducing Inappropriate Medication Use & Polypharmacy. IGRIMUP now includes more than 140 international experts from 26 countries.