A Treatment for Brown Bag Syndrome—Deprescribing

Polypharmacy

Author: Linda Law MD

Over the years I was an attending physician in Emergency Departments, it was a common event for patients to bring all their medications to the ER in a brown paper bag.  These patients were usually elderly, and their polypharmacy was often a cause of drug-induced symptoms. Polypharmacy is defined as taking five or more medications a day, but patients were known to bring in ten or more prescriptions at times. In fact, over a quarter of US senior hospitalizations are caused by medication-related problems[1].

Deprescribing may be one effective method to address polypharmacy. As defined by Wade Thompson, HBSc, deprescribing is “the process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes.”  A conscious uncoupling (see Gwyneth Paltrow) for the healthcare setting.

Medications that were prescribed in the past for semi-acute or chronic conditions may no longer be necessary.  Or as patients age, the preventative value of a drug may decrease. A “brown-bag” review can identify drugs to be deprescribed.  Remember, not all drugs can be stopped abruptly. Some, like beta-blockers, need to have their dose tapered down.  Importantly, an appropriate healthcare provider should oversee changes and stoppages in medications.

In 2015, a Canadian expert panel identified five classes of drugs that should be high priorities to consider deprescribing in the elderly. The panel used information from literature searches and surveys of experts in geriatric healthcare. They concluded the most important classes of medications to deprescribe are benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants and proton-pump inhibitors. Douglas S. Paauw, Professor of Medicine at University of Washington School of Medicine, has published a list of 11 medications he recommends deprescribing. Benzodiazepines, statins and proton pump inhibitors also make his list.

Drug Class Example (generic)
Benzodiazepines Diazepam, Alprazolam, Flurazepam, Clonazepam
Atypical antipsychotics Aripiprazole, Clozapine, Risperidone, Quetiapine
Statins Atorvastatin, Fluvastatin, Lovastatin, Rosuvastatin
Tricyclic antidepressants Desipramine, Doxepin, Clomipramine, Amitriptyline
Proton-pump inhibitors Esomeprazole, Rabeprazole, Lansoprazole, Pantoprazole

 

Deprescribing is an excellent time for patients and healthcare providers to participate in shared decision-making.  For more information on deprescribing and the Canadian Study, see the Medscape article https://www.medscape.com/viewarticle/847187.

[1] https://www.medscape.com/viewarticle/847187_2

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