Deprescribing recommendations: an essential consideration for clinical guideline developers

One area of focus of the Bruyère Evidence-Based Deprescribing Guidelines Symposium held in March 2018 was encouraging the routine inclusion of deprescribing recommendations in clinical guidelines. Clinical guidelines often do not accommodate frailty or patients with multiple comorbid conditions. This can give rise to complex medication regimens and risk of medication harm. Despite monitoring and stopping treatment being a key part of rational prescribing, deprescribing is often overlooked in general and in the context of guidelines. There are several challenges to increasing deprescribing recommendations in clinical guidelines. These include limited evidence on the effects of deprescribing, lack of awareness among guideline developers, potential conflicts of interest, and lack of incentives for deprescribing research. To date, medicines regulators, payers, governments, and journals have not encouraged the inclusion of deprescribing recommendations in guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system could address some of these challenges through its focus on values and preferences, distinct rating of quality of evidence and strength of recommendations, downgrading quality due to indirect evidence, and an explicit approach to conflicts of interest. Further work to adapt GRADE methods to deprescribing could be of benefit. Establishing deprescribing recommendations as a routine part of clinical guidelines is an important opportunity to improve evidence-based clinical practice, and ultimately, patient care.</p

Deprescribing: future directions for research

A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies

Quality of anticoagulation and use of warfarin-interacting medications in long-term care: A chart review-2

<p><b>Copyright information:</b></p><p>Taken from "Quality of anticoagulation and use of warfarin-interacting medications in long-term care: A chart review"</p><p>BMC Geriatrics 2008;8():13-13.</p><p>Published online 3 Jul 2008</p><p>PMCID:PMC2464578.</p><p></p

Quality of anticoagulation and use of warfarin-interacting medications in long-term care: A chart review-1

<p><b>Copyright information:</b></p><p>Taken from "Quality of anticoagulation and use of warfarin-interacting medications in long-term care: A chart review"</p><p>http://www.biomedcentral.com/1471-2318/8/13</p><p>BMC Geriatrics 2008;8():13-13.</p><p>Published online 3 Jul 2008</p><p>PMCID:PMC2464578.</p><p></p

The Cameroon Mobile Phone SMS (CAMPS) Trial: A Randomized Trial of Text Messaging versus Usual Care for Adherence to Antiretroviral Therapy

<div><h3>Background</h3><p>Mobile phone technology is a novel way of delivering health care and improving health outcomes. This trial investigates the use of motivational mobile phone text messages (SMS) to improve adherence to antiretroviral therapy (ART) over six months.</p> <h3>Methodology/Principal Findings</h3><p>CAMPS was a single-site randomized two-arm parallel design trial in Yaoundé, Cameroon. We enrolled and randomized HIV-positive adults on ART, aged 21 years and above to receive a weekly standardized motivational text message versus usual care alone. The primary outcome was adherence measured using a visual analogue scale (VAS), number of doses missed (in the week preceding the interview) and pharmacy refill data. Outcomes were measured at 3 and 6 months. Service providers and outcome assessors were blinded to allocation. Analysis was by intention-to-treat. Between November and December 2010, 200 participants were randomized, with 101 in the intervention group and 99 in the control group. At 6 months, overall retention was 81.5%. We found no significant effect on adherence by VAS>95% (risk ratio [RR] 1.06, 95% confidence interval [CI] 0.89, 1.29; p = 0.542; reported missed doses (RR 1.01, 95% CI 0.87, 1.16; p>0.999) or number of pharmacy refills (mean difference [MD] 0.1, 95% CI: 0.23, 0.43; p = 0.617. One participant in the intervention arm reported a possible disclosure of status.</p> <h3>Conclusions/Significance</h3><p>Standardized motivational mobile phone text messages did not significantly improve adherence to ART in this study. Other types of messaging or longer term studies are recommended.</p> <h3>Registration</h3><p>1. Pan-African Clinical Trials Registry; <a href="http://clinicaltrials.gov/ct2/show/PACTR201011000261458">PACTR201011000261458</a></p> <p>2. Clinicaltrials.gov; <a href="http://clinicaltrials.gov/ct2/show/NCT01247181">NCT01247181</a></p> </div

Deprescribing guidelines: an international symposium on development, implementation, research and health professional education

Deprescribing is a clinically important and feasible innovation that ensures medication efficacy, reduces harms, and mitigates polypharmacy. It involves reducing doses or stopping medications that are not useful, no longer needed, or which may be causing harm. It may also involve changing to a safer agent or using non-pharmacological approaches for care instead. Clinical guidelines combined with behaviour changes (of health care providers (HCPs), the public, and health care decision-makers) are needed to integrate deprescribing into routine practice. Using rigorous international standards, the Bruyère Research Institute Deprescribing Guidelines research team validated a ground-breaking deprescribing guideline methodology and developed or co-developed 5 evidence-based deprescribing guidelines. In March 2018, the team hosted an international symposium convening HCPs, researchers, public agencies, policymakers, and patient advocates in Ottawa, Ontario, Canada. This 3-day symposium aimed to facilitate knowledge exchange amongst guideline developers, users, and the public; initiate partnerships and collaborations for new deprescribing guideline recommendations and effectiveness research; and to continue work on HCP deprescribing education activities. An interprofessional planning committee developed an overall agenda, and small groups worked on session objectives and formats for different components: methods for rigorous deprescribing guideline development, implementation experiences, research/evaluation experiences and educational needs. Through a series of keynote speakers, panel discussions, and small working groups, the symposium provided a forum for participants to meet one another, learn about their different experiences with deprescribing guidelines, and develop collaborations for future initiatives. One hundred thirty participants, from 10 countries and representing over 100 institutions and organizations took part. Symposium proceedings are presented in this issue of RSAP for sharing with the wider community engaged in the care of patients with problematic polypharmacy

CONSORT flow diagram for CAMPS trial.

<p>CONSORT flow diagram for CAMPS trial.</p

Outcomes at 6 months.

<p>(SMS: short message service; RR: risk ratio; CI: confidence interval; SD: standard deviation; MD: mean difference; VAS: visual analogue scale; BMI: body mass index; OI: opportunistic infection; CD4: CD4-positive-T-lymphocyte; SF: short form).</p>*<p>Bonferroni adjustment for secondary outcomes: 0.05/8 = 0.006.</p>¥<p>Insufficient data for CD4 count (n = 34 for intervention and 26 for control; MD-24.4; 95% CI: −101.3, 52.6; p = 0.599) and viral load (n = 0).</p>μ<p>P-values obtained using the chi-squared test and the t-test for binary and continuous outcomes respectively.</p

Outcomes at 3 months.

<p>(SMS: short message service; RR: risk ratio; CI: confidence interval; SD: standard deviation; MD: mean difference; VAS: visual analogue scale; BMI: body mass index; OI: opportunistic infection; CD4: CD4-positive-T-lymphocyte; SF: short form).</p>*<p>Bonferroni adjustment for secondary outcomes: 0.05/8 = 0.006.</p>¥<p>Insufficient data for viral load (n = 0).</p>μ<p>P-values obtained using the chi-squared test and the t-test for binary and continuous outcomes respectively.</p

Satisfaction with the text message among the participants who received text messages (n = 101).

*<p>Percentages may not add up to 100 due to rounding off.</p