Reams of articles have been written on when drug treatments should be initiated, but far less literature is available on when they should be discontinued. A recent analysis of Medicare records found that, rather than stopping pharmacotherapy and resorting to hospice care, almost 12% of cancer patients in 1999 received chemotherapy in the last two weeks of life, up 2% from 1983.
Just when is it appropriate to stop medications? A recently published commentary in the March 27 issue of Archives of Internal Medicine proposes a process for medication prescribing in older persons that considers remaining life expectancy and therapeutic goals.
"Pharmacists can educate physicians in a collaborative way about medications to consider changing and medications to consider reducing the dose of or discontinuing completely," said Holly Holmes, M.D., a coauthor of the paper and an instructor of medicine in the division of geriatrics at the University of Chicago-Pritzker School of Medicine. "Unfortunately, such communication does not often happen. Pharmacists, like physicians, can get stuck in the confines of prescribing within the current guidelines. The challenge becomes knowing when those guidelines no longer make sense."
"What complicates this issue is the fact that the decision to discontinue a particular drug or drugs is a multifactorial one. Little empirical research currently exists that describes how to make those decisions using rules or algorithms," agreed Ilene Zuckerman, Pharm.D., Ph.D., an associate professor at the University of Maryland School of Pharmacy in Baltimore and director of medication appropriateness studies at the University of Maryland's Peter Lamy Center for Drug Therapy and Aging. "Determining what medications, if any, could be discontinued should really be an individualized process."
Fortunately, pharmacists in many settings do have access to a complete list of medications that a patient is taking-a very important first step, Zuckerman said. Pharmacists, particularly those who specialize in or have a particular interest in geriatric medicine, also have a broad knowledge base about the risks and benefits of particular drugs.
If patients are on 10 or more medications and there appears to be some duplication, or if patients themselves express the desire to simplify their regimen, pharmacists can advise them to consult their doctor about whether all of the drugs are truly necessary, Holmes suggested. She said that this is especially true of older persons with multiple medical problems.
Holmes continued by pointing out that pharmacists are often the last healthcare providers patients see before they go home and start to take their medication. As such, she explained, pharmacists are in a unique position to caution patients not to discontinue medications without first consulting their physician, because monitoring may be necessary and some medications cannot be discontinued abruptly.
Pharmacists have a completely different viewpoint from physicians, because they are on the opposite side of a given situation, Holmes said. The patient has gone to multiple physicians and gotten multiple prescriptions, but because no one is communicating, the pharmacist becomes the final keeper of all the information. That is a powerful position for pharmacists to be in, but only if they use it, she added.
Holmes continued by saying that in the best-case scenarios, pharmacists express their concerns by saying something on the order of, "Can I talk to you for a minute about your medications? You might want to talk to your doctor about whether all of these medications are really necessary," and it then becomes the patient's responsibility to do something. Unfortunately, Holmes said, this approach is a little too complex to do with computerized drug utilization review at this time.
Pharmacists can play a key role in educating patients about the benefits of selective discontinuation of certain drugs in their regimen, said G. Caleb Alexander, M.D., a co-author of the paper and an assistant professor of medicine at the University of Chicago. Alexander, Holmes, and Zuckerman all acknowledged that this is a role that pharmacists can play throughout a patient's lifetime.