Polypharmacy, often defined as taking five or more medications at the same time, has been associated with a variety of adverse health outcomes. Therapy with a medication is initiated when the patient and care team conclude that the benefits of taking the medication outweigh the risks of not starting therapy. However, over time, patients and their conditions or goals of care change, new evidence is discovered, and other factors can tip the balance, such that the benefits no longer outweigh the risks or burdens of continued treatment. Few, if any, medications should be continued on a lifelong basis. Patients and caregivers should be made aware of the planned duration of therapy and the outcomes desired, and should feel empowered to follow up with providers to ensure that the benefits of therapy continue to outweigh the risks. The performance of medication reconciliation and transitions of care—such as admission to or discharge from a hospital—may serve as critical activities for deciding whether to continue therapy or create a plan to safely stop a medication.
Barnsteiner JH. Medication Reconciliation: Transfer of medication information across settings-keeping it free from error. Am J Nursing. 2005 Mar; 105(3 Suppl):31-36.
Bootsma N, et al. Deprescribing: Managing Medications to Reduce Polypharmacy. Institute for Safe Medication Practice Canada. [Internet]. 28 Mar 2018. [Accessed 17 Jul 2018].
Cipolle RJ, et al. Pharmaceutical care practice: the patient-centred approach to medication management services. 3rd ed. New York: McGraw-Hill; 2012.
De Vries, TPGM, et al. “Step 6: Monitor (and stop?) the treatment”. Guide to good prescribing: a practical manual. Geneva: World Health Organization. 1994:79-83. [Internet].
Garfinkel D, et al. Routine deprescribing of chronic medications to combat polypharmacy. Ther Adv Drug Saf. 2015 Dec;6(6):212-233. PMID:26668713.
Halapy H, et al. Ascertaining Problems with Medication Histories. Can J Hosp Pharm. 2012 Sep;65(5):360-367. PMID:23129864.
ISMP Canada. Five Questions to Ask about your Medications. [Internet]. [Accessed 20 Dec 2018].
The “time to benefit” is the period between initiation of an intervention (in this case, a medication) and the point when the patient begins to experience a benefit. This period varies from one medication to another. Treatment with a medication is usually not indicated unless the “time to benefit” is clearly shorter than the patient’s life expectancy and any potential adverse effects are deemed manageable. These factors are particularly relevant for older adults and those receiving palliative care.
Holmes HM, et al. Rationalizing Prescribing for Older Patients with Multimorbidity: Considering Time to Benefit. Drugs Aging. 2013 Sep;30(9):655-666. PMID:23749475.
In many cases, a proton pump inhibitor (PPI) is initiated for a valid indication, in cases where the benefits outweigh the risks. During a hospital stay, PPIs may be started for stress ulcer prophylaxis or for patients who will receive certain treatments that increase the likelihood of high-risk gastrointestinal conditions. After the patient’s risk for stress ulcer returns to baseline the PPI should be stopped. In addition, patients who did not require a PPI before their hospital admission typically will not need to continue taking one of these drugs after the underlying reason for PPI therapy has been addressed.
Long-term adverse effects associated with the acid inhibition caused by PPIs are now emerging. Patients should talk to their healthcare team and only continue taking PPIs if the benefits truly outweigh the risks and to obtain advice on how to taper the dose towards discontinuation if warranted.
Boghossian TA, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 Mar 16;3:CD011969. PMID:28301676.
Cochrane. Stopping or reducing vs continuing long-term proton-pump inhibitor use in adults. [Internet]. 2017 Mar 16. [Accessed 20 Dec 2018].
Deprescribing Guidelines and Algorithms. [Internet]. [Accessed 20 Dec 2018].
Kinoshita Y, et al. Advantages and Disadvantages of Long-term Proton Pump Inhibitor Use. J Neurogastroenterol Motil. 2018 Apr 30;24(2):182–196. PMID:29605975.
Therapeutics Initiative: Independent Healthcare Evidence. Deprescribing Proton Pump Inhibitors. [Internet]. 26 Jun 2018. [Accessed 20 Dec 2018].
Broad-spectrum antibiotics are effective in treating bacterial infections, particularly life-threating infections such as sepsis or febrile neutropenia. In certain high-risk situations, these drugs may be clinically indicated and started at the first signs or symptoms of an infection. Broad-spectrum antibiotics should be stopped as soon as the causative pathogen is known or suspected. Targeted antibiotic therapy should begin as soon as possible. When a broad-spectrum antibiotic is deemed necessary, it should be used for the shortest possible duration, according to guideline recommendations and the patient’s clinical response.
Centers for Disease Control and Prevention. Antibiotic Prescribing and Use in Hospitals and Long-Term Care. [Internet]. Updated 11 Apr 2017. [Accessed 29 Jan 2019].
Government of Canada. Antibiotic (antimicrobial) resistance: Protecting yourself and your family. [Internet]. Updated 13 Nov 2018. [Accessed 20 Dec 2018].
Hildreth CJ, et al. Inappropriate Use of Antibiotics. JAMA. 2009 Aug 19;302(7):816.
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Zalmanovici Trestioreanu A, et al. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015 Apr 8;4:CD009534. PMID: 25851268.
Non-pharmacologic options to treat insomnia, such as sleep hygiene and cognitive behavioural therapy, are less harmful than drugs, and should be first line therapy.
Canadian Agency for Drugs and Technologies in Health. Sleep Medications for Adults Diagnosed with Insomnia: Clinical Evidence and Harm. [Internet]. 29 Apr 2013. [Accessed 20 Dec 2018].
Canadian Agency for Drugs and Technologies in Health. Current Practice Analysis: Interventions for Insomnia Disorder. [Internet]. June 2017. [Accessed 20 Dec 2018].
Fick DM, et al. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-2246. PMID:26446832.
Soong C, et al. Less Sedatives for Your Older Relative: A toolkit for reducing inappropriate use of benzodiazepines and sedative-hypnotics among older adults in hospitals. [Internet] July 2017. [Accessed 20 Dec 2018].
Evidence shows that opioids are not more effective than other analgesics for certain chronic pain conditions. Furthermore, evidence is mounting that the risks of opioid treatment, including opioid use disorder, overdose, and other previously under-recognized side effects (e.g., hyperalgesia, psychomotor impairment [which can increase the risk of fractures], myocardial infarction, sexual dysfunction) support the use of non-opioid therapy.
Thorough patient-centred discussion about risks, benefits, and expectations is essential.
Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666; PMID:28483845.
Busse JW, et al. Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA. 2018 Dec 18;320(23):2448-2460. PMID:30561481.
Canadian Agency for Drugs and Technology in Health. Evidence Bundles: Alternatives to Opioids. [Internet]. [Accessed 20 Dec 2018].
Canada Agency for Drugs and Technology in Health. Opioids for the Treatment of Pain. [Internet]. September 2018. [Accessed 20 Dec 2018].
The Institute for Safe Medication Practices Canada. Opioid Pain Medicines Information for Patients and Families. [Internet]. March 2017. [Accessed 20 Dec 2018].
Krebs EE, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. PMID:29509867.
Encouraging thoughtful conversations about the harms associated with opioid prescribing.