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Deprescribing in palliative care

Jo Thompson
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DOI: https://doi.org/10.7861/clinmedicine.19-4-311
Clin Med July 2019
Jo Thompson
ARoyal Surrey County Hospital / St Luke's Cancer Centre, Guildford, UK
Roles: lead nurse, supportive and palliative care
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  • For correspondence: jothompson3@nhs.net
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    Box 1.

    Steps to deprescribing

    • Take detailed medication history including indication for each drug.

    • Consider potential for drug induced harm ie age of patient, comorbidities, number of medications, types of medications.

    • Consider each individual medication and the potential to provide ongoing benefit.

    • Prioritise medications for deprescribing (usually one at a time), give explanations to patient. Agree follow-up arrangements.

    • Carry out follow-up assessment to assess effects of deprescribing. Consider further deprescribing.

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    Box 2.

    Barriers to deprescribing1,2,8,9

    • Limited time.1

    • Lack of clarity over whose role it is to deprescribe. 8

    • Concern regarding stopping medications initiated by specialists. 1

    • Uncertainty regarding the ongoing benefits of medications. 1

    • Concern over drug withdrawal effects. 2

    • Uncertainty regarding the timing of deprescribing discussions when goals of care are unclear. 1

    • Concern from healthcare professionals that patients may feel they are ‘giving up hope’. 9

    • Reluctance from patients to change medications. 2

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    Table 1.

    The OncPal deprescribing guideline.

    Class of medicationMedicationSituations of limited benefit
    AspirinAspirinPrimary prevention
    Lipid lowering medicationsStatins
    Fibrates
    Ezetimibe
    All indications
    Blood pressure lowering medicationsACE inhibitors
    Sartans
    Beta blockers
    Calcium channel blockers
    Thiazide
    Diuretics
    Mild to moderate hypertension
    Secondary prevention of cardiovascular events
    Management of stable coronary artery disease
    Anti-ulcer medicationsProton pump inhibitors
    H2 antagonists
    All indications unless recent history of gastrointestinal bleeding, peptic ulcer, gastritis, GORD, or the concomitant use of NSAIDs and steroids
    Oral hypoglycaemicsMetformin
    Sulfonylureas
    Thiazolidinediones
    DPP-4 inhibitors
    GLP-1 analogues
    Acarbose
    Mild hyperglycaemia (prevention of diabetic complications)
    Osteoporosis medicationsBisphosphonates
    Raloxifene
    Strontium
    Denosumab
    All indications except hypercalcaemia
    Vitaminsn/aAll except treatment of low serum concentrations
    Mineralsn/aAll except treatment of low serum concentrations
    Complementary therapiesn/aAll indications
    • Adapted with permission from Lindsay J, Dooley M, Martin J et al. The development and evaluation of an oncological palliative care deprescribing guideline: the ‘OncPal deprescribing guideline’. Support Care Cancer 2015;23:71–8.

      ACE = angiotensin-converting enzyme; DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; GORD = gastro-oesophageal reflux disease; NSAIDs = nonsteroidal anti-inflammatory drugs; n/a = not applicable.

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Deprescribing in palliative care
Jo Thompson
Clinical Medicine Jul 2019, 19 (4) 311-314; DOI: 10.7861/clinmedicine.19-4-311

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Deprescribing in palliative care
Jo Thompson
Clinical Medicine Jul 2019, 19 (4) 311-314; DOI: 10.7861/clinmedicine.19-4-311
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  • Article
    • ABSTRACT
    • Key points
    • Introduction
    • Polypharmacy
    • Barriers to deprescribing
    • Deprescribing tools
    • Medication classes suitable for deprescribing
    • Conclusion
    • References
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