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Addressing Polypharmacy in Outpatient Dialysis Units

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Marisa Battistella argues that there is a need to emphasize the new generation of data that demonstrate improved outcomes when a patient stops a medication to decrease polypharmacy.

Image courtesy of interviewee. March 14, 2024

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This video video discusses polypharmacy, which is defined as the concurrent use of multiple medications, typically five or more per day. It is particularly prevalent among individuals on hemodialysis, who average 12 medications daily. Chronic kidney disease patients are at higher risk for polypharmacy due to various comorbidities and complicated healthcare interactions.

This video video explains the “prescribing cascade,” where adverse effects of a medication are mistaken for new conditions, leading to further prescriptions and exacerbating polypharmacy. The consequences of polypharmacy include adverse drug reactions, drug interactions, poor medication adherence, cognitive impairment, increased emergency visits, and higher healthcare costs.

To address these issues, the concept of de-prescribing is introduced, which involves the systematic process of reducing or discontinuing medications that pose risks or are no longer beneficial. A pilot study was implemented in a hemodialysis unit in Toronto, where specific de-prescribing algorithms for certain medications (e.g., alpha blockers, loop diuretics, statins) were developed and validated. The study demonstrated that these algorithms were safe and effective in reducing polypharmacy.

Building on this, additional medications were added to the de-prescribing regimen, and patient-centered tools were created to engage patients in the process. The initiative aims to expand this de-prescribing program to more hemodialysis units across Canada, assessing its effectiveness using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). The ultimate goal is to integrate de-prescribing into routine practice for improving the quality of life for patients on multiple medications, ensuring better medication management across various populations, including transplant patients and those in kidney care clinics.

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Lemme start, by describing what polypharmacy is,

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and then I can get into some of our work in our,

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our specific study.

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Um, polypharmacy refers to the use of multiple medications.

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Typically, it's defined as five or more medications per day.

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And it's a major issue, particularly in,

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people on hemodialysis

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who actually take 12 medications per day on average.

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And, people with,

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chronic kidney disease are vulnerable to polypharmacy

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for several reasons, including,

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having many comorbidities such as hypertension, diabetes,

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cardiovascular disease.

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And these all require long-term medication management.

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They also have many interactions

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with different healthcare providers,

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and there are multiple transit, care transitions.

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And this may all lead to a lack of effective communication,

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between prescribers.

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Furthermore, people

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with a chronic kidney disease are predisposed

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to a problematic, prescribing cascade,

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and this exacerbates, poly pharmacy.

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So what is the, prescribing cascade?

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It's when a medication is prescribed

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and an adverse event occurs,

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and this is misinterpreted as a new disease.

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And so then, another medication is prescribed

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to treat this, new disease.

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And, and this, and this scope happens, continuously.

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And so we can see how this, can actually lead

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to polypharmacy.

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There are consequences to polypharmacy,

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and there are numerous,

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they include adverse drug reactions,

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drug drug interactions, not adherence to,

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to their medications.

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Um, increased risk of cognitive impairment, which can lead

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to, impaired balance and falls.

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And this can lead to more frequent emergency,

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department visits as well as hospitalizations.

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And this all increases, morbidity and even mortality.

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And finally, polypharmacy can even lead to,

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increased healthcare costs.

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One way to manage polypharmacy is call is de-prescribing

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and de-prescribing the planned supervised process

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of discontinuing medications that may be causing harm

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or no longer have any benefit.

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And this is definitely one way to manage medications

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or optimize medications and minimize polypharmacy.

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So we actually studied this, and we did a pilot study.

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So first our research team identified five medication

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classes to, to be, to focus on deprescribing.

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And so those were alpha blockers, such

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as prazocin loop diuretics such as furosemide,

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potton pump inhibitors such as pantoprazole, quinine,

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and statins such as atorvastatin.

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And so what we did is we developed

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and validated these d prescribing algorithms for each

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of these specific, medications.

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And so we incorporated disease specific guidance on tapering

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patient education and safety monitoring for each

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Of these medications.

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And then we conducted,

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a prospective quality improvement study in our outpatient

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hemodialysis unit in Toronto, Canada.

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And where this is where we actually,

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used the Deprescribing tool in our clinical practice.

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And our pilot study, demonstrated

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that medication specific deprescribing algorithms were safe

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and locally effective in reducing polypharmacy in patients

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on dialysis.

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So where did that take us?

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So informed by some of the lessons and patient

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and clinician feedback from this pilot,

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we revised the five algorithms

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and we added four more medications

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and developed, deprescribing algorithms

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for four more medications, which included allopurinol,

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gabapentinoids, benzodiazepines,

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and pro kinetic agents such as medical prm.

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We also, developed

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and validated, patient centered tools.

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So we created a, like a bulletin, a pamphlet on each

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of these medications and a whiteboard video to go along

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with, that bulletin.

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And so this allowed patients to understand

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and engage in the discussion 2D prescribe.

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So to translate these positive outcomes for, Canadians

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and as well as international patients on hemodialysis,

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we thought a wider evaluation is needed

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to further ascertain its safety and,

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and effectiveness, as well as to develop

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an implementation guidance to support broad adopt,

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broad adoption into different hemodialysis units.

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So currently our team is, implementing

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and evaluating these de-prescribing

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algorithms intervention in an in expanded selection

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of Canadian hemodialysis units.

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So, first we started here in Toronto,

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and that is that

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that implementation study is just finishing now.

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Halifax Nova Scotia started, in September

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and we're hoping to onboard a site in, Calgary,

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Alberta, and then one in British Columbia.

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And so the aim is

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to generate an a validated standardized de-prescribing

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program that is easily implemented across different

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hemodialysis units.

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Uh, in Canada, what we're doing is we're using the re aim

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framework, which is reach effectiveness, adoption,

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implementation, and maintenance.

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Um, and really it's to evaluate the safety

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and effectiveness of de-prescribing, intervention,

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the feasibility, and

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to assess whether it has the intended effect to help

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refine the delivery and to provide evidence,

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for continued support to, to really make this part of,

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clinical practice.

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We're hoping to finish up this implementation study in the

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next year to year

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and a half, analyze the results, refine, you know, the tool

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so that it can be used, across more centers,

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In Canada, including other parts of the world.

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Um, but we're also hoping to take these algorithms,

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refine them and use them in different, settings such

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as in the transplant population, the pre-dialysis,

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or the sort of kidney care clinic patients.

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And so we're really hoping that,

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these algorithms will become just part of routine practice

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where we're optimizing, optimizing,

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medication use in the different populations,

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specifically patients who take a lot

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of medications every day.

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Overall, I think medication specific algorithms will assist

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the Deprescribing initiative by outlining

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decision making process in a practical manner that's useful

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for all members of the healthcare team, including, you know,

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the physicians, nurses, pharmacists,

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dieticians and social workers.

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We believe our patient Deprescribing tools are designed

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to allow patients to understand

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00:06:52.705 --> 00:06:54.885
and engage in the discussion to de-prescribe.

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And this hopefully will increase their willingness

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to de-prescribe when it's indicated.

146
00:07:00.125 --> 00:07:02.905
So ultimately, I think the goal of our, our work,

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00:07:02.965 --> 00:07:05.785
our study is to integrate effective de-prescribing practices

148
00:07:05.975 --> 00:07:08.985
into routine care, to optimize medication use

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00:07:09.085 --> 00:07:12.625
and really improve the quality of life, especially in people

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00:07:12.725 --> 00:07:13.225
who are.

Managing Polypharmacy in Hemodialysis Patients

00:00:00 - Lemme start, by describing what polypharmacy is, and then I can get into some of our work in our, our specific study. polypharmacy refers to the use of multiple medications. Typically, it's defined as five or more medications per day. And it's a major issue, particularly in, people on hemodialysis who actually take 12 medications per day on average. And, people with, chronic kidney disease are vulnerable to polypharmacy for several reasons, including,
00:00:33 - cardiovascular disease. And these all require long-term medication management. They also have many interactions with different healthcare providers, and there are multiple transit, care transitions. And this may all lead to a lack of effective communication, between prescribers. Furthermore, people with a chronic kidney disease are predisposed to a problematic, prescribing cascade,
00:01:04 - So what is the, prescribing cascade? It's when a medication is prescribed and an adverse event occurs, and this is misinterpreted as a new disease. And so then, another medication is prescribed to treat this, new disease. And, and this, and this scope happens, continuously. And so we can see how this, can actually lead to polypharmacy. There are consequences to polypharmacy, and there are numerous, they include adverse drug reactions,
00:01:36 - to their medications. increased risk of cognitive impairment, which can lead to, impaired balance and falls. And this can lead to more frequent emergency, department visits as well as hospitalizations. And this all increases, morbidity and even mortality. And finally, polypharmacy can even lead to, increased healthcare costs. One way to manage polypharmacy is call is de-prescribing
00:02:07 - of discontinuing medications that may be causing harm or no longer have any benefit. And this is definitely one way to manage medications or optimize medications and minimize polypharmacy. So we actually studied this, and we did a pilot study. So first our research team identified five medication classes to, to be, to focus on deprescribing. And so those were alpha blockers, such as prazocin loop diuretics such as furosemide,
00:02:40 - and statins such as atorvastatin. And so what we did is we developed and validated these d prescribing algorithms for each of these specific, medications. And so we incorporated disease specific guidance on tapering patient education and safety monitoring for each Of these medications. And then we conducted, a prospective quality improvement study in our outpatient hemodialysis unit in Toronto, Canada.

Improving Polypharmacy Management in Dialysis Patients

00:03:11 - used the Deprescribing tool in our clinical practice. And our pilot study, demonstrated that medication specific deprescribing algorithms were safe and locally effective in reducing polypharmacy in patients on dialysis. So where did that take us? So informed by some of the lessons and patient and clinician feedback from this pilot, we revised the five algorithms and we added four more medications and developed, deprescribing algorithms
00:03:45 - gabapentinoids, benzodiazepines, and pro kinetic agents such as medical prm. We also, developed and validated, patient centered tools. So we created a, like a bulletin, a pamphlet on each of these medications and a whiteboard video to go along with, that bulletin. And so this allowed patients to understand and engage in the discussion 2D prescribe.
00:04:17 - and as well as international patients on hemodialysis, we thought a wider evaluation is needed to further ascertain its safety and, and effectiveness, as well as to develop an implementation guidance to support broad adopt, broad adoption into different hemodialysis units. So currently our team is, implementing and evaluating these de-prescribing algorithms intervention in an in expanded selection
00:04:46 - So, first we started here in Toronto, and that is that that implementation study is just finishing now. Halifax Nova Scotia started, in September and we're hoping to onboard a site in, Calgary, Alberta, and then one in British Columbia. And so the aim is to generate an a validated standardized de-prescribing program that is easily implemented across different
00:05:15 - in Canada, what we're doing is we're using the re aim framework, which is reach effectiveness, adoption, implementation, and maintenance. and really it's to evaluate the safety and effectiveness of de-prescribing, intervention, the feasibility, and to assess whether it has the intended effect to help refine the delivery and to provide evidence, for continued support to, to really make this part of, clinical practice. We're hoping to finish up this implementation study in the
00:05:48 - and a half, analyze the results, refine, you know, the tool so that it can be used, across more centers, In Canada, including other parts of the world. but we're also hoping to take these algorithms, refine them and use them in different, settings such as in the transplant population, the pre-dialysis, or the sort of kidney care clinic patients. And so we're really hoping that, these algorithms will become just part of routine practice

Optimizing Medication Use: The De-prescribing Initiative

00:06:22 - medication use in the different populations, specifically patients who take a lot of medications every day. Overall, I think medication specific algorithms will assist the Deprescribing initiative by outlining decision making process in a practical manner that's useful for all members of the healthcare team, including, you know, the physicians, nurses, pharmacists, dieticians and social workers. We believe our patient Deprescribing tools are designed
00:07:12 - and engage in the discussion to de-prescribe. And this hopefully will increase their willingness to de-prescribe when it's indicated. So ultimately, I think the goal of our, our work, our study is to integrate effective de-prescribing practices into routine care, to optimize medication use and really improve the quality of life, especially in people who are.

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