Pharmacist
Canadian Pharmacists Association Last updated: September 2023
-
Side effects of drugs are often misdiagnosed as symptoms of another medical condition, and as a result, patients may be prescribed one or more drugs to treat the adverse drug reactions (ADRs). This is called a prescribing cascade. Prescribing cascades may contribute to unnecessary or potentially unsafe medication use. This has several risks, such as drug interactions, increased frequency or severity of further side effects, unnecessary drug costs, and poor medication adherence. Prescribing cascades can also impact a patient’s quality of life and lead to avoidable emergency room visits, hospital admissions and health system costs. Health practitioners should always question whether a new symptom or problem is a potential side effect of a current medication , especially in older adults, and avoid prescribing or recommending additional drug treatment until this possibility has been thoroughly investigated.
Sources:
Cadogan CA, et al. Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many. Drug Saf. 2016 Feb;39(2):109-16. PMID: 26692396.
Gill SS, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005 Apr 11;165(7):808-13. PMID: 15824303.
Hsu HF, Chen KM, Belcastro F, Chen YF. Polypharmacy and pattern of medication use in community-dwelling older adults: A systematic review. J Clin Nurs. 2021;30(7-8):918-28. PMID: 33325067.
Nguyen PV, et al. Prescribing cascade in an elderly woman. Can Pharm J (Ott). 2016;149(3):122-4. PMID: 27212961.
Savage RD, Visentin JD, Bronskill SE, et al. Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA Intern Med. 2020;180(5):643-651. PMID: 32091538.
Sherman JJ, Davis L, Daniels K. Addressing the Polypharmacy Conundrum. US Pharm. 2017;42(6):14-20.
Singh S, Cocoros NM, Haynes K, et al. Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer’s Disease. J Am Geriatr Soc. 2021;69(5):1328-1333. PMID: 33432578.
Sternberg SA, Guy-Alfandary S, Rochon PA. Prescribing cascades in older adults. CMAJ. 2021;193(6):E215. PMID: 33558408.
Trenaman SC, Harding A, Bowles SK, Kirkland SA, Andrew MK. A Prescribing Cascade of Proton Pump Inhibitors Following Anticholinergic Medications in Older Adults With Dementia. Front Pharmacol. 2022;13:878092. Published 2022 Jun 22. PMID: 35814221.
Rochon PA, et al. The prescribing cascade revisited. Lancet. 2017 May;389(10081):1778–80. PMID: 28495154.
-
There is no evidence to support the use of low-dose codeine pain medication over non-opioid analgesics. Codeine also has potential for abuse and dependence within a short time frame of regular or excessive use. Non-prescription codeine products are often supplied in combination with non-opioid analgesics (i.e., NSAIDs and acetaminophen). In addition to concerns regarding codeine abuse and dependence, misuse of these codeine-containing combination analgesics may also result in serious adverse effects due to high doses of the non-opioid analgesic component (ibuprofen, acetaminophen or ASA), which may include liver toxicity, gastric perforation, haemorrhage and peptic ulcer, renal failure, chronic blood loss anaemia and low blood potassium (with potential fatal heart and neurological complications), as well as the potential for allergic reactions in some populations (those with asthma). In addition, a high percentage of patients may not metabolize codeine to active morphine due to an altered CYP2D6 enzyme, which may increase the risk of adverse effects from codeine.
Sources:
Cazet L, Bulteau S, Evin A, et al. Interaction between CYP2D6 inhibitor antidepressants and codeine: is this relevant?. Expert Opin Drug Metab Toxicol. 2018;14(8):879-886. PMID: 29963937.
Frei MY, et al. Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases. Med J Aust. 2010 Sep 6;193(5):294-6. PMID: 20819050.
McAvoy BR, et al. Over-the-counter codeine analgesic misuse and harm: characteristics of cases in Australia and New Zealand. N Z Med J. 2011 Nov 25;124(1346):29-33. PMID: 22143850.
Robinson GM, et al. Misuse of over-the-counter codeine-containing analgesics: dependence and other adverse effects. N Z Med J. 2010 Jun 25;123(1317):59-64. PMID: 20657632.
Van Hout MC, et al. Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies. Int J Drug Policy. 2016 Jan;27:17-22. PMID: 26454626.
Young C, Loshak H. Medications containing low-dose codeine for the treatment of pain and coughs. CADTH Health Technology Review. 2021 Aug; 1(8).
-
One in four Canadians over the age of 65 are prescribed 10 or more different medications.. With each new drug, the risk of adverse drug reactions and subsequent hospitalization of the patient increases. In order to ensure the safety and appropriateness of therapy, all health care practitioners should assess to the therapeutic indication for a patient’s drug therapy and start or renew medication only once they have determined that the benefits of therapy outweigh the risks to the patient. Remember the acronym IESU -Indicated/ Effective/ Safety/ (Patient) Use.
Sources:
Birtcher K, Allen L, et al. 2022 ACC Expert Consensus Decision Pathway for Integrating Atherosclerotic Cardiovascular Disease and Multimorbidity Treatment: A Framework for Pragmatic, Patient-Centered Care. J Am Coll Cardiol. 2023 Jan, 81 (3) 292–317. PMID: 36307329.
Canadian Institute for Health Information. Drug use among seniors in Canada. Accessed August 30, 2023. [Internet].
Frank C, et al. Deprescribing for older patients. CMAJ. 2014 Dec 9;186(18):1369-76. PMID: 25183716.
Holmes HM. Rational prescribing for patients with a reduced life expectancy. Clin Pharmacol Ther. 2009 Jan;85(1):103-7. PMID: 19037198.
Hilmer SN, et al. Thinking through the medication list: appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician. 2012 Dec;41(12):924-8. PMID: 23210113.
Jetha S. Polypharmacy, the Elderly, and Deprescribing. Consult Pharm. 2015;30(9):527-532. PMID: 26350893.
Lee SJ, Kim CM. Individualizing Prevention for Older Adults. J Am Geriatr Soc. 2018;66(2):229-234. PMID: 29155445.
Nusair MB, et al. How pharmacists check the appropriateness of drug therapy? Observations in community pharmacy. Res Social Adm Pharm. 2017 Mar – Apr;13(2):349-357. PMID: 27102265.
-
Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs in Canada, and many are becoming available as non-prescription medications. While generally safe and well-tolerated for short-term use/ as needed use in treating gastro-esophageal reflux disease (GERD), PPIs are often used longer than needed. Further, PPIs have been associated with a number of adverse effects which may increase with a patient’s age or long-term use though the causality of many of these adverse effects is uncertain. Some adverse effects associated with long-term use of PPIs include increased risk of fracture, Clostridium difficile infection and diarrhea, community-acquired pneumonia (CAP), vitamin B12 deficiency, and hypomagnesemia. Guidelines recommend short-term use of PPIs (e.g. < 8-12 weeks) for most patients treated for GERD or peptic ulcer disease. They also suggest regular attempts at deprescribing PPIs when patients do not have a valid indication for continued use. This might include reducing the dose, tapering and stopping, or switching to on-demand PPI use. These guidelines do not apply to patients with Barrett esophagus, severe esophagitis grade C or D, chronic NSAID/anticoagulant use with bleeding risk, a documented history of bleeding gastrointestinal ulcers, or those on triple antithrombotic therapy, who have an indication for continued PPI use.
Sources:
Choosing Wisely Canada. Bye-bye PPI [Internet]. 2017 July [cited 2017 Jun 26].
D’Silva KM, Mehta R, Mitchell M, et al. Proton pump inhibitor use and risk for recurrent Clostridioides difficile infection: a systematic review and meta-analysis [published online ahead of print, 2021 Jan 16]. Clin Microbiol Infect. 2021;S1198-743X(21)00035-5. PMID: 33465501.
Farrell B, Lass E, Moayyedi P, Ward D, Thompson W. Reduce unnecessary use of proton pump inhibitors. BMJ. 2022;379:e069211. Published 2022 Oct 24. PMID: 36280250.
Farrell B, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-64. PMID: 28500192.
Poly TN, Islam MM, Yang HC, Wu CC, Li YJ. Proton pump inhibitors and risk of hip fracture: a meta-analysis of observational studies. Osteoporos Int. 2019;30(1):103-114. PMID: 30539272.
Shanika LGT, Reynolds A, Pattison S, Braund R. Proton pump inhibitor use: systematic review of global trends and practices [published online ahead of print, 2023 Jul 7]. Eur J Clin Pharmacol. 2023;10.1007/s00228-023-03534-z. PMID: 37420019.
Turner JP, Thompson W, Reeve E, Bell JS. Deprescribing proton pump inhibitors. Aust J Gen Pract. 2022;51(11):845-848. PMID: 36310001.
Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022;162(4):1334-1342. PMID: 35183361.
-
Between 2005 and 2012, the sedating properties of certain atypical antipsychotics have led to a 300% increase in their off-label use for insomnia. Guidelines report a lack of evidence of benefit for atypical antipsychotics for the treatment of insomnia and warn against their possible adverse effects, including weight gain, fall risk and metabolic disorders. While antipsychotics may be appropriate in some patients with insomnia when there is another indication for their use ( e.g., as adjunctive treatment in depression), the use of these medications as first-line therapy for insomnia is discouraged due to potential harm that outweighs their benefits Deprescribing guidelines suggest that antipsychotics used for insomnia can be safely stopped with or without taper.
Sources:
Anderson SL, Vande Griend JP. Quetiapine for insomnia: A review of the literature. Am J Health Syst Pharm. 2014;71(5):394-402. PMID: 24534594.
Bjerre LM, Farrell B, Hogel M, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Can Fam Physician. 2018;64(1):17-27. PMID: 29358245.
Canadian Psychiatric Association. First-line treatment for insomnia should not include routine use of antipsychotics, say Canadian psychiatrists [Internet]. 2015 Jun [cited 2017 Jun 26]. Available from: .
Coe HV, et al. Safety of low doses of quetiapine when used for insomnia. Ann Pharmacother. 2012 May;46(5):718-22. PMID: 22510671.
Modesto-Lowe V, Harabasz AK, Walker SA. Quetiapine for primary insomnia: Consider the risks. Cleve Clin J Med. 2021;88(5):286-294. Published 2021 May 3. PMID: 33941603.
Shah C, et al. Controversies in the use of second generation antipsychotics as sleep agent. Pharmacol Res. 2014 Jan;79:1-8. PMID: 24184858.
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. PMID: 27998379.
Thompson W, et al. Atypical antipsychotics for insomnia: a systematic review. Sleep Med. 2016;12(6):13-17. PMID: 27544830.
-
Benzodiazepines are commonly prescribed drugs in Canada for anxiety disorders and insomnia. Strong evidence shows that long-term use of benzodiazepines in older persons is associated with tolerance, dependence and adverse effects, including sedation, impaired memory and cognition, falls, hip fractures, depression, and increased hospital admissions. Use in younger persons can lead to chronic dependence. Prescribing guidelines recommend exploring alternative non-pharmacological such as cognitive behavioural therapy for insomnia (CBT-I) prior to prescribing benzodiazepines for insomnia. If determined to be beneficial for the patient, benzodiazepines should not usually be prescribed for long-term use and discontinuation strategies should be built into the patient’s treatment plan, such as gradual dose tapering.
Sources:
Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry. 2005 May;18(3):249-55. PMID: 16639148.
Baillargeon L, et al. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ. 2003;169(10):1015-20. PMID: 14609970.
Chang F. Strategies for benzodiazepine withdrawal in seniors: Weaning patients off these medications is a challenge. Can Pharm J. 2005 Nov 1; 138(8):38-40.
Chen L, et al. Discontinuing benzodiazepine therapy: An interdisciplinary approach at a geriatric day hospital. Can Pharm J. 2010 Nov 1;143(6):286-95.
Gallagher HC. Addressing the issue of chronic, inappropriate benzodiazepine use: how can pharmacists play a role? Pharmacy. 2013;1(2):65-93.
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-133. PMID: 27136449.
Pottie K, et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Can Fam Physician. 2018;64(5):339-351. PMID: 29760253.
Wang Y, Wilson DL, Fernandes D, et al. Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. J Clin Med. 2023;12(5):1788. Published 2023 Feb 23. PMID: 36902574.
-
The Canadian Pharmacists Association (CPhA) established its Choosing Wisely Canada top six recommendations in two phases. The first phase comprised a call to pharmacists and pharmacy researchers from across Canada for recommendations in the fall of 2016. During the second phase, an expert committee was formed to review and finalize the recommendations submitted from the call to pharmacists. The committee was composed of CPhA member association representatives, pharmacy researchers, CPhA Board of Directors and staff who have broad knowledge and experience in pharmacy practice and quality improvement. Criteria used by the committee to finalize the list included relevance to practising pharmacists, impact and the available evidence to support each recommendation. The final list was approved by CPhA member associations and Board of Directors.
Opioid Wisely
Encouraging thoughtful conversations about the harms associated with opioid prescribing.