Characteristics of Study Patients (Cases and Controls).

*<p>Net family income in Canadian dollars (1 Canadian dollar = 1.2 US dollars).</p>†<p>Romano commorbidity score calculated using data from 365 days prior to the index date.</p>‡<p>History within 5 years prior to the index date.</p>§<p>Dispensing of a drug within 365 days prior to index date.</p

Risk of Myocardial Infarction for Rosiglitazone Compared to Pioglitazone and Sulfonylureas in Patients Who Received Metformin as First-Line Drug Treatment.

*<p>CI denotes confidence interval.</p>†<p>The current cumulative exposure period is the number of months of continuous exposure prior to the event (for cases) or matched index date (controls). Cumulative current exposure includes continuous drug use up until the index date. Exposure that was accumulated prior to any lapse in therapy of greater than 90 days was defined as past exposure.</p>‡<p>Odds ratios have been adjusted for matching variables (age in 5-year groupings, sex, family income band in $5,000 dollar increments, number of family members, and existence of supplemental coverage).</p>§<p>Odds ratios have been adjusted for (in addition to the matching variables) the time since initiation of metformin, the following within 5 years of the index date: congestive heart failure (hospitalization for ICD-9 428 or a physician visit for same plus a prescription for furosemide), angiography, coronary artery bypass graft, percutaneous transluminal angioplasty, ischemic stroke (hospitalization for ICD-9 433, 434, or 436), transient ischemic attack (hospitalization for ICD-9 435), angina (ICD-9 412–414), prior AMI, renal disease (ICD-9 584–586, 403–404); and the following within one year of index: Romano comorbidity score, exposure to nitrates, statins, angiotensen II converting enzyme inhibitors or receptor blockers, thiazide diuretics, calcium channel blockers, beta blockers, clopidogrel, digoxin, warfarin, insulin, and past use of metformin, glitazones and sulfonylureas.</p

Characteristics of Type II Diabetes Patients with Myocardial Infarction and Their Matched Controls^*.

*<p>Odds ratios have been adjusted for matching variables (age in 5-year groupings, sex, family income band in $5,000 dollar increments, number of family members, and existence of supplemental coverage). CI denotes confidence interval.</p>†<p>Net family income band in Canadian dollars from the most recent federal income tax return (1 Canadian dollar = 1.2 US dollars).</p>‡<p>Romano commorbidity score calculated using data from 365 days prior to the index date.</p>§<p>History within 5 years prior to the index date.</p>∥<p>Dispensing of a drug within 365 days prior to index date.</p

Within-Drug Comparison of Glitazone Exposure and Sulfonylurea Exposure in Myocardial Infarction Cases and Matched Controls who received Metformin as First-Line Drug Therapy.

*<p>CI denotes confidence interval.</p>†<p>The current cumulative exposure period is the number of months of continuous exposure prior to the event (for cases) or matched index date (controls). Cumulative current exposure includes continuous drug use up until the index date. Exposure that was accumulated prior to any lapse in therapy of greater than 90 days was defined as past exposure.</p>‡<p>Odds ratios have been adjusted for matching variables (age in 5-year groupins, sex, family income band in $5,000 dollar increments, number of family members, and existence of supplemental coverage).</p>§<p>Odds ratios have been adjusted for (in addition to the matching variables) time since initiation of metformin, the following within 5 years of the index date: congestive heart failure, angiography, coronary artery bypass graft, percutaneous transluminal angioplasty, ischemic stroke, transient ischemic attack, angina, prior AMI, renal disease; and the following within one year of index: Romano comorbidity score, exposure to nitrates, statins, angiotensen II converting enzyme inhibitors or receptor blockers, thiazide diuretics, calcium channel blockers, beta blockers, clopidogrel, digoxin, warfarin, insulin, and past use of metformin, glitazones and sulfonylureas.</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

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