Medication Review and Rationalisation of Medicines for Adult Patients with a Limited Prognosis - Good Practice Guidance

Publication: 01/06/2022  
Next review: 01/06/2025  
Clinical Guideline
CURRENT 
ID: 7628 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Medication Review and Rationalisation of Medicines for Adult Patients with a Limited Prognosis Good Practice Guidance

This guidance is intended for use by healthcare professionals when caring for patients with a limited prognosis  (days to short years) due to advanced age, frailty, comorbidity and/or disease, where goals of care are moving towards optimising symptoms and quality of life rather than prolonging survival. This guidance has been designed to support clinical decision making when reviewing and rationalising medication for these patients and builds on the LTHT Specialised Palliative Team (SPCT) Care ‘Good Practice Guidance - Deprescribing for Palliative Care Patients’.

The three key aims of a medication review and rationalisation of medicines are:

  • Stop unnecessary or harmful medicines through  ‘deprescribing’,
  • Review long term illness control and medication side-effects and flag to GP/specialist as required,
  • Start/continue medicines which could provide symptom benefit.

As part of the review, the intended benefits and potential risks of medications (including interactions, side effects and burden of medications) should be discussed with the patient and potentially their GP and/or specialist if appropriate. Ultimately, the goal is to reduce polypharmacy, improve adherence with beneficial medications and improve quality of life. When life expectancy is short and symptom control is the priority then the use of preventative medicines for the prevention of long-term complications, over years to decades, become less important.

Deprescribing is an effective way of rationalising medicines and is the planned and supervised process of intentionally stopping a medication or reducing its dose that might be causing harm or no longer be of benefit. The practice of deprescribing involves a stepwise, patient-centred approach that is not about denying effective treatment but reducing the risks and burden of taking multiple medicines. It is important to consider that the balance of risks and benefits of a particular medicine will be influenced by the needs and concerns of each individual patient.

The following table can be used to aide clinical decisions about medication alongside individual patient assessment

  • Stop medications unlikely to have a beneficial use
  • Review long term illness control and medication side-effects and flag to GP/specialist as required
  • Continue medications likely to have continued benefit

Medication Rationalisation Principles

  • Medication rationalisation is a shared decision making process between the patient and the healthcare professional. It is important to determine what matters to the patient.
  • Take a detailed medication history including indication for each drug.
    • What drugs are you taking? Names, doses and frequency? Do you have any problems with taking your medications e.g. remembering, swallowing, and side effects?
  • Consider the potential for medication harm for example age of the patient, fragility, comorbidities, number of drugs and renal or liver impairment.
  • For each medicine identify what is essential and non-essential by considering the:
  • If continuing ensure dose is optimised and route appropriate, any need for memory aids, change of preparation.
  • If discontinuing a drug: prioritise the order to be ceased (usually one at a time), how to cease (immediate vs. weaning). See Medstopper 6 for advice on how to stop medicines.
  • Provide explanation to patient and carer. Agree follow-up arrangements.
  • Carry out follow-up assessment to assess effects of medication changes. Consider further medication changes.
  • Communicate & document all drug changes with the patient/carer and all relevant healthcare professionals involved in the patients care
  • Drugs need to be reviewed again when the patient is in the last 1 to 2 weeks of life, when consideration should be given to discontinuing these drugs, again taking into account what matters to the patient.

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Drug or Drug Class

Prognosis Long Months to Short Years 
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
 *Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

PPIs / H2 - receptor antagonists e.g omeprazole, lansoprazole, ranitidine

Continue if symptom benefit or history of GI bleeds PU, gastritis, GORD or concomitant use of NSAIDs and steroids. Ensure lowest effective dose. 

Consider stopping - unlikely to give symptom benefit. 

Endocrine

Oral hyperglycaemic agents

e.g. metformin, sulfonylureas, thiazolidinediones, DPP-4 inhibitors. GLP-1 analogues, acarbose.  

Review - Aim for CBG target range 6 - 15mmol/L (discuss with the patient), with a corresponding HbA1c 53 - 97 (mmol/mol). Consider step by step reduction working backwards from NICE guidelines.

Diabetes UK Guidance towards EOL 7

Consider involving DSNs if there are issues or potential issues with control.

Review - Aim for blood glucose levels between 6 and 15 mmol/L to avoid symptoms (discuss with the patient). Consider reducing or stopping particularly if losing weight and eating less).

Diabetes UK Guidance towards EOL7

 

Stop. Check blood glucose if concerning hypo/hyperglycaemia symptoms.

See Palliative Care intranet page; Managing diabetes at the end of life8

Insulin

Review - Aim for CBG target range 8-15mmol/L (discuss with the patient) but up to 15mmol/L acceptable, with corresponding HbA1c 53 - 97 (mmol/mol). Consider reduction in Insulin if hypoglycaemia or weight loss.

Consider involving DSNs if there are issues or potential issues with control.

Diabetes UK Guidance towards EOL7

Continue - consider long acting if possible & keep under review. May need reduced dose.

Monitor blood glucose daily or if concerning hypo/hyperglycaemia symptoms.

Diabetes UK Guidance towards EOL7

Type 2 diabetes - See Palliative Care intranet page; Managing diabetes at the end of life8

Type 1 diabetes, pancreatitis or CF related - continue insulin. See Palliative Care intranet page; Managing diabetes at the end of life8

Seek advice from diabetes team if concerns, particularly if glucose control is unstable, a sliding scale or an insulin pump is in use.

Thyroid hormones

Continue to avoid hypothyroidism & associated symptoms and consider checking thyroid status.

Continue until oral route is lost. 

Osteoporosis e.g. weekly bisphosphonates, strontium

Review indication, consider stopping if limited benefit, and continue if on long term steroids.

Stop - no benefit with limited prognosis unless for treatment of hypercalcaemia or bone pain.

Stop – no symptom benefit

Oestrogens hormones

Review indication consider stopping if previous VTE or Breast Cancer

Stop – no symptom benefit

Drug or Drug Class

Prognosis Long Months to Short Years
*consider that the patient may wish to continue their medicines

Prognosis Weeks to Months
*consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Cardiovascular

 

 

 

Antihypertensive
ACE inhibitors, ARBs (e.g. losartan), beta blockers, calcium channel blockers, thiazides, diuretics

NB: need to clarify indication as can be used for indications other than for lower blood pressure

Hypertension

Consider - risk of orthostatic hypotension and falls. This risk is heightened by other factors such confusion, infection and abnormal fluid balance.

Benefits of treating hypertension will be less in patients with a shorter prognosis.

Suggested target systolic BP >130 - 139 mmHg.

Prioritise stopping medication that solely affects BP.

Consider continuing, in order of priority:

1. Anti-hypertensives used also for  symptomatic control  (e.g. anti-anginals or rate control, diuretics for symptomatic CCF)

2. Antihypertensives used for other prevention effects (e.g. ACEI in stroke, LVSD).
pressure

Blood Pressure in frail older adults 9

Hypertension

Reviewconsider risk of orthostatic hypotension and falls. Screen by checking lying and sitting/standing BP. If BP readings are erratic will need multiple readings. Consider other medications that might be contributing to low BP or postural drop.

The need for antihypertensives is likely to reduce. Limited benefit in mild to moderate hypertension. If more than one antihypertensive, stop sequentially working backwards through algorithm and monitor.

 

Hypertension

Stop - no symptom benefit.

Congestive Cardiac Failure (CCF)

Review - indication/benefit/burdens. Consider reducing or stopping if:

- Low BP
- Hyperkalaemia
- Multiple antihypertensives

Stop – no symptom benefit 

Diuretics

e.g. furosemide, bumetanide 

Review indication/ benefit - if for CCF continue at maximum tolerated dose to control symptoms.

Thiazide diuretics - review and consider stopping/changing if the following present: hypokalaemia, hyponatraemia, hypercalcaemia, gout.

CCF - Review. Continue if providing symptom relief. Consider SC furosemide if loss of PO route 

Drug or Drug Class

Prognosis Long Months to Short Years
*Consider that the patients may wish to continue their medicines 

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Beta blockers for rate control, e.g. bisoprolol, atenolol  

Review indication/benefit - consider stopping If history of bradycardia, heart block, asthma and hypoglycaemia episodes.

In CCF, if beta-clocker not tolerated or contraindicated then digoxin can be useful alternative as it has a positive inotropic effect.

Continue at maximum tolerated dose to control CCF and angina (rate control) symptoms. 

Stop - no symptom benefit 

Hyperlipidaemia drugs e.g. statins, fibrates, ezetimide

Review indication/ benefit- consider stopping if life expectancy less than <10 years for primary prevention. Continue in recent MI if expected survival at >5 years post MI.

Stop - offers no short term benefits for all indications.

Stop - offers no short term benefits for all indications.

Antianginals e.g. beta blockers, isosorbide mononitrate, nicorandil

Review indication/benefit- may not be needed if mobility is reduced and unlikely to worsen symptoms, gradual reduction recommended. (Check patient has GTN spray for symptoms).

Stop - no symptom benefit.

Ensure patient has adequate pain relief

Digoxin

For rate control and CCF management continue.

Review indication/benefit and consider dose reduction or stopping;

- If normal systolic ventricular function
- High dose and renal impairment.

Review indication/benefit - can be poorly tolerated in the frail. Continue for rate control and CCF management.

Stop - no symptom benefit

Peripheral vasodilators e.g. nifedipine

Review indication/benefit - may be used to treat muscle spasm & continue if providing symptom benefit. 

Review indication/benefit - may be used to treat muscle spasm & continue if providing symptom benefit.

Review indication/benefit - continue if providing symptom benefit and PO route tolerated.

Antiarrhythmic e.g. Amiodarone

Continue if providing symptom benefit.

Review indication/benefit- may no longer be needed.

Stop - no symptom benefit

Drug or Drug Class

Prognosis long months to short years
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Antiplatelet and anticoagulants

Antiplatelets e.g. aspirin, clopidogrel, dipyridamole 

Primary prevention: review indication/risk /benefit for aspirin and consider stopping.

Post stent: review risk/ benefits and consider discussion with specialities

Anti-platelets post-stent insertion

Secondary prevention: review indication/benefit.

If on dual anti-platelets consider rationalising.  

Generally continue post TIA/stroke

Secondary prevention: consider indication & review risks vs. benefits.

Stop - no symptom benefit.

Primary prevention: stop - no symptom benefit.

Anticoagulants oral e.g. warfarin, DOACs (rivaroxaban, apixaban, dabigatran, edoxaban)

Review indication/risks (bleeding) vs. benefit (VTE/ischaemic events).

Atrial fibrillation/flutter - consider switching warfarin to a DOAC if suitable.

VTE treatment or prevention of recurrence -consider switching warfarin to a DOAC if suitable.

Consider reducing to prevention dose of rivaroxaban or apixaban if on a full dose DOAC and > 6 months since event.

Mechanical valve - consider changing to injectable anticoagulant (LMWH) if there are particular risks of continuing warfarin. DOACs are not suitable for this indication.

Antiphospholipid syndrome - consider changing to injectable anticoagulant (LMWH) if there are particular risks of continuing warfarin.

Thrombosis in unusual sites (e.g. portal vein, cerebral vein, mesenteric vein) consider switching to LMWH but if unsuitable discuss options with haemostasis/thrombosis team

Arterial thrombosis/PVD - discuss with vascular team regarding switches or alternative treatment

In all cases- consider changing to injectable anticoagulant (LMWH) if there are particular risks of continuing oral anticoagulation

Stop dabigatran (Direct thrombin inhibitor) if CrCl <30mL

Stop DOACs: apixaban/edoxaban/rivaroxaban (factor Xa inhibitors) if CrCl < 15ml/min

DOACs - review if current dose is correct dose for patient with respect to age, renal function, weight

CHADVASCc Score

HAS-BLED

ORBIT

Review indication/risks (bleeding) vs. benefit (VTE/ischaemic events).

Atrial fibrillation/flutter - if on warfarin consider switching to a DOAC  if suitable

VTE treatment or prevention of recurrence - if on warfarin consider switching to a DOAC if suitable.

Consider reducing to prevention dose of rivaroxaban or apixaban, if on a full dose DOAC and > 6 months since event.

Mechanical valve - consider changing to injectable anticoagulant (LMWH) if there are particular risks or concerns of continuing warfarin.  DOACs are not suitable for this indication. In the final weeks if the patient wants to continue it may be appropriate to reduce INR target to 2.5 to avoid high INRs and over-testing.

Antiphospholipid syndrome- consider changing to injectable anticoagulant (LMWH) if there are particular risks of continuing warfarin. Could consider a DOAC if only VTE events.

Thrombosis in unusual sites (e.g. portal vein, cerebral vein, mesenteric vein) consider switching to LMWH but if unsuitable discuss options with haemostasis/thrombosis team

Arterial thrombosis/PVD - discuss with vascular team regarding switches or alternative treatment

In all cases- consider changing to injectable anticoagulant (LMWH) if there are particular risks of continuing oral anticoagulation

Stop dabigatran (Direct thrombin inhibitor) if CrCl <30mL,

Stop DOACs: Apixaban/edoxaban/rivaroxaban (factor Xa inhibitors) if CrCl < 15mL/min

DOACs - review if current dose is correct dose for patient with renal function, weight.

 

 

Stop - no symptom benefit.

 

Anticoagulants injectable e.g. LMWH, fondaparinux 

Prophylactic: continue only if increased VTE risk. If struggling with injections DOACS may be an option though unlicensed.

 

Prophylactic: stop - no symptom benefit.

Therapeutic: continue after considering patients QoL, consider whether oral anticoagulation may be appropriate or once a day injections if on twice daily.

Therapeutic - stop unless concerns about worsening symptoms

Drug or Drug Class

Prognosis long months to short years
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Respiratory System

Inhalers: Anti-muscarinic bronchodilators

e.g. ipratropium, tiotropium 

Beta-2-agonists

e.g. salbutamol

Steroids inhalers e.g. beclomethasone 

Continue may provide symptom benefit. See LTHT COPD guidance 10and LTHT Asthma guidance11

Check able to use current inhaler bronchodilators.

Consider stopping  bronchodilators (anti-muscarinic & beta-2-agonist) if: 

1. Narrow angle glaucoma
2. Bladder outflow obstruction (un-catheterised)

Continue until patient unable to use medications

Theophylline

Continue -may provide symptom relief but check if inhalers can be optimised. Theophylline requires monitoring.

Stop - unlikely to be of benefit in last days

CNS

 

 

 

Dementia e.g donepezil, memantine  

Review benefit. May be appropriate to stop (Dementia deprescribing guidance )12

Stop - no symptom benefit

Parkinson’s disease e.g. Madopar 

Continue. Symptom benefit. Consider rotigotine TD patch if unable to swallow

Continue. Consider rotigotine TD patch if unable to swallow (see rotigotine guidance)13

Antiepileptics for seizures or neuropathic pain

e.g. levetiracetam, phenytoin, sodium valproate, carbamazepine

 

Seizures:  Continue. Symptom benefit. 

Seizures:  Continue - symptom benefit. Consider switching to SC route &/or midazolam when unable to swallow. Seek advice from LTHT SPCT if unsure. 

Neuropathic pain:  Continue. Symptom benefit. 

Neuropathic pain: Review. Continue if providing symptom benefit & PO route tolerated. 

Neuropathic drugs e.g. gabapentin, amitriptyline 

Continue. Symptom benefit. 

Continue until oral route is lost. Symptom benefit. 

Antipsychotics for psychiatric disorder e.g. olanzapine, lithium 

Continue. Consider referral to speciality if unsure.  

Avoid sudden cessation. Consider alternative drug if PO route lost rapidly and consider discussion with speciality if unsure.  

Drug or Drug Class 

Prognosis long months to short years
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Antipsychotics for nausea & vomiting or agitation e.g. haloperidol, levomepromazine 

Continue. Symptom benefit. 

Continue. Symptom benefit. Consider alternative route. 

Antidepressants

Tricyclic Antidepressants (TCAs e.g. amitriptyline),

SSRIs (e.g. citalopram), SNRIs (e.g. mirtazapine, venlafaxine) 

Continue for symptom management. Consider gradual withdrawal if no clinical benefit.

Mirtazapine: can help with sleep & is an appetite stimulant. Risk of hyponatraemia.

TCAs:  consider stopping in: dementia, glaucoma, heart conductive abnormalities, constipation, prostatism, high falls risk. If prescribed for pain benefits may outweigh burden.

SSRIs:  consider alternative if hyponatraemia or high falls risk. Note citalopram is associated with QT prolongation & consider ECG particularly if history of unexplained syncopal episodes.

Consider flagging to GP and initiating gradual reduction if appropriate.

Continue for symptom management. Consider gradual withdrawal if deteriorating to pre-empt loss of PO route.

Stop. No symptom benefit.

Benzodiazepines e.g. lorazepam, diazepam, midazolam and ‘Z’ drugs e.g. zopiclone

Review and consider reduction or stopping if increased risk of falls, long duration of use.

Consider GP review to help manage reduction in benzodiazepines.

 

Long term use - continue. Attempt gradual withdrawal if patient wishes. Consider oral diazepam to aid withdrawal.

Short term (agitation &/or seizures) - likely symptom benefit - continue.

Continue. Consider alternative route/formulation.

Antihistamines e.g. cetirizine, chlorpheniramine

Review indication. Continue if providing symptom relief from itch or allergies.

If concerned about anticholinergic burden consider switching chlorpheniramine (high anticholinergic burden).

Stop unless providing specific symptom relief & PO route still tolerated

Drug or Drug Class 

Prognosis long months to short years
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Anticholinergics e.g.

Oxybutynin, tiotropium, solifenacin, tolterodine, cyclizine, amitriptyline

Review and consider stopping if:

1. Dementia (increased risk of confusion and falls), 2. Antipsychotic meds (opposite effect to anticholinergics), 3. Constipation (side effect), 4. Glaucoma (can precipitate)
5. Prostatism (increases risk).
Avoid anticholinergics combinations.  See  Anticholinergics guidance (Anticholinergic tool)3

Stop. No symptom benefit.

Opioids e.g. morphine, oxycodone

Review indication, risk/benefits.  Continue at lowest dose to control symptoms and consider regular laxatives. See opioid guidance.14

Continue. Symptom benefit. Consider alternative route. See opioid guidance.

Genito urinary medicine

Alpha receptor blockers

e.g Doxazosin, Prazosin, Tamsulosin

Continue. May provide symptom benefit e.g. painful bladder spasm.

Consider stopping if catheter in situ, orthostatic hypotension, or micturition syncope.

Review indication. Continue for painful bladder spasm until oral route lost.

Consider stopping for prostatic symptoms. 

5 alpha reductase inhibitor

e.g. finasteride, dutasteride

Continue. May provide symptom benefit e.g. painful bladder spasm. Consider stopping if catheter in situ or no longer indicated for BPH. Consider alternatives such as tamsulosin or mirabegron (if cognitive impairment or antimuscarinic burden)

Stop to reduce tablet burden or when PO route is lost.

Phosphodiesterase type 5 inhibitors e.g sildenafil 

Considering stopping if CCF or nitrate therapy.

Stop to reduce tablet burden or when PO route is lost.

Musculoskeletal system

 

NSAIDs
Ibuprofen, Naproxen

Continue if symptom benefit and consider PPI.

Consider stopping if bleeding, concurrent oral steroids, antiplatelet, or CKD (eGFR <50).

Increase risk of bleeding with SSRIs.

May be appropriate to continue. Consider SC paracoxib when oral route is lost,

Paracetamol

Continue if clear symptom benefit. Caution in frail (Paracetamol Guidance)15 - risk of overdosing and tablet burden.  

Stop to reduce tablet burden or when PO route is lost.

Steroids e.g. dexamethasone, fludrocortisone, prednisolone

Review indication, risk/benefits.

If taking long term - review and consider if dose needs doubling while unwell.

Consider adverse effects & long term side effects e.g.  hypertension, diabetes, muscle weakness, osteoporosis and need for PPI +/- bone protection +/- PCP prophylaxis (co-trimoxazole)

Ensure CBG monitoring, indication, review & stop date are specified. See steroids and hyperglycaemia guidance 16

Review indication - may be appropriate if needed for symptom management & to prevent withdrawal symptoms. Consider alternative route if PO route lost. Seek advice if necessary.

Drug or Drug Class 

Prognosis long months to short years
*Consider that the patients may wish to continue their medicines

Prognosis Weeks to Months
*Consider that the patient may wish to continue their medicines

Prognosis Days
*consider that the patient may wish to continue their medicines

Disease Modifying Anti-Rheumatic Drugs e.g. methotrexate, sulfasalazine 

Review indication. Continue if symptom benefit. Discuss with expert before stopping.

Stop. No symptom benefit. 

Colchicine

Stop if eGFR <10

Stop. No symptom benefit.

Quinine

Stop if no benefit, known to prolong QTc

Stop. No symptom benefit.

Other

 

Vitamin & mineral supplements e.g. calcium, folate, iron, vit B or D, supplement drink

Review and consider stopping if no benefit.

Continue if felt to have benefit i.e. iron for anaemia, calcium supplements.

Consider continuing vitamin D if deficient.  

Stop. No symptom benefit.

Dietary supplements

e.g. herbal supplement, vitamins and minerals

Consider stopping if no benefit

Drops, sprays, ointments, creams e.g. moisturisers 

Review indication & continue if benefit

Review indication & continue if symptom benefit. 

Review. Continue only if patient still able to use and benefit 

Antibacterials

Review indication & continue if for acute symptom benefit. Ensure indication, review & stop date are specified. Considering stopping prophylactic antibiotics.

Unlikely to be appropriate -used occasionally for symptom management at the end of life. 

Antifungals

Review indication & continue if symptom benefit. Ensure indication, review & stop date are specified.

Oral thrush - considering continuation as may provide symptom benefit.  

Ophthalmology

Topical non- selective beta-blockers e.g. timolol, betaxolol, levobunolol

Consider stopping if bradycardia, heart block, heart failure, asthma.

Stop. No symptom benefit.

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Provenance

Record: 7628
Objective:
Clinical condition:
Target patient group: Patients with a limited prognosis (days to short years) due to advanced age, frailty, comorbidity and/or disease
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References and Guidance Resources/Links

  1. Numbers needed to treat https://managemeds.scot.nhs.uk/for-healthcare-professionals/efficacy-nnt
  2. SPC https://www.medicines.org.uk/emc
  3. Anticholinergic guidance https://managemeds.scot.nhs.uk/for-healthcare-professionals/hot-topics/anticholinergics/ and  Anticholinergic tool http:/www.acbcalc.com
  4. Cumulative Toxicity and Adverse Drug Reactions (ADRs) tool Cumulative Toxicity and Adverse Drug Reactions (ADRs) tool
  5. Medication and falls risk in older person Medication and falls risk in older person tool
  6. Medstopper Medstopper
  7. Diabetes https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
  8. Diabetes last days of life http://lthweb.leedsth.nhs.uk/sites/palliative-care/pharmacy/diabetes-mangement-in-the-last-days-and-hours-of-life
  9. Blood pressure and elderly Age Ageing. 2020 Aug 24;49(5):807-813. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444671/
  10. LTHT COPD
  11. LTHT Asthma
  12. Dementia  (algorithm-for-deprescribing.pdf (sydney.edu.au)
  13. LTHT rotigine
  14. LTHT Opioids
  15. LTHT Paracetamol http://www.leedsformulary.nhs.uk/docs/4.7.1paracetamolreduceddosingadults.pdf?UNLID=564303520211220141135
  16. LTHT Steroids and hyperglycaemia

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Good Practice Guidance - Deprescribing for Palliative Care Patients

Appendix

Deprescribing describes the process of identifying and discontinuing medications with little or no benefit and potential harm, in order to improve quality of life. It is common for patients who are being treated with palliative intent to still be prescribed multiple medications, often aimed at primary or secondary prevention despite their prognosis being in the region of weeks to months. These are often only discontinued in the final days of life when the patients are no longer able to swallow. The practice of deprescribing involves a stepwise, patient-centred process that is not about denying effective treatment but reducing the risks and burden of taking multiple medications.

Deprescribing Principles

  • Deprescribing is a shared decision making process between the patient and the healthcare professional. It is important to determine what matters to the patient.
  • Take a detailed medication history including indication for each drug.
  • Consider the potential for drug harm for example age of the patient, fragility, comorbidities, number of drugs and renal or liver impairment.
  • For each drug identify what is essential and non-essential by considering the:
  • If continuing ensure dose is optimised and route appropriate.
  • If discontinuing drugs: prioritise the order to be ceased (usually one at a time), how to cease (immediate vs. weaning). See Medstopper for advice on how to stop medicines.
  • Provide explanation to patient and carer. Agree follow-up arrangements.
  • Carry out follow-up assessment to assess effects of deprescrining. Consider further deprescribing.
  • Communicate & document all drug changes with the patient/carer and all relevant healthcare professionals involved in the patients care.
  • Drugs need to be reviewed again when the patient is in the last 1 to 2 weeks of life, when consideration should be given to discontinuing these drugs, again taking into account what matters to the patient.

Note: Blue box indicates possible drugs to target

Drug class

Prognosis months to weeks
*Consider that the patient may wish to continue their medicines 

Prognosis days
*Consider that the patient may wish to continue their medicines. 

PPIs / H2 - receptor antagonists e.g. omeprazole, lansoprazole, ranitidine. 

Continue if recent history of GI bleeds, PU, gastritis, GORD or concomitant use of NSAIDs and steroids. Ensure lowest effective dose.

Consider stopping - unlikely to give symptom benefit.

Oral hypoglycaemic agents
e.g. metformin, sulfonylureas, thiazolidinediones, DPP-4 inhibitors. GLP-1 analogues, acarbose.  

Review - Aim for blood glucose levels between 6 and 15 mmol/l to avoid symptoms (discuss with the patient). Consider reducing or stopping particularly if losing weight and eating less.).

Stop. Check blood glucose if concerning hypo/hyperglycaemia symptoms.

Insulin

Continue - consider long acting if possible & keep under review may need reduced dose. Monitor blood glucose daily or if concerning hypo/hyperglycaemia symptoms.

Type 2 diabetes- see Palliative Care intranet page; Managing diabetes at the end of life. Type 1 diabetes, pancreatitis or CF related - continue insulin. Seek advice from diabetes team.

Osteoporosis e.g. weekly bisphosphonates, strontium

Stop - no benefit with limited prognosis unless for treatment of hypercalcaemia or bone pain.

Stop -no symptom benefit.

Antihypertensives
ACE inhibitors, sartans, beta blockers, calcium channel blockers, thiazides, diuretics.

NB: need to clarify indication as can be used for indications other than for lower blood pressure.

Review - check BP. Need for antihypertensives likely to reduce. Limited benefit for mild to moderate hypertension/ secondary prevention of cardiovascular events/ management of stable coronary artery disease.

If more than one antihypertensive, stop sequentially working backwards through algorithm & monitor.

Stop - no symptom benefit.

Hyperlipidaemia drugs e.g. statins, fibrates, ezetimide.

Stop - offers no short term benefits for all indications.

Stop- no symptom benefit.

ACE Inhibitors & Angiotensin 2 inhibitors for CCF

Continue.

Stop - no symptom benefit.

Beta blockers for rate control, e.g. bisoprolol. 

Continue at maximum tolerated dose to control HF and angina (rate control) symptoms.

Stop - no symptom benefit.

Diuretics for CCF e.g. furosemide, bendroflumethazide, spironolactone.

Review indication. Continue at maximum tolerated dose to control CCF symptoms.

Review. Continue if providing symptom relief. Consider SC furosemide if loss of PO route.

Digoxin

Review. Can be poorly tolerated in the frail. Continue for rate control and CCF management.

Stop - no symptom benefit.

Antianginals e.g. beta blockers, isosorbide mononitrate, nicorandil.

Review. May not be needed if mobility is reduced.

Stop - no symptom benefit.

Antiarrhythmic e.g. amiodarone. 

Review may no longer be needed.

Stop - no symptom benefit.

Antiplatelets e.g. aspirin, clopidogrel, dipyridamole. 

Secondary prevention: consider indication & review risks vs. benefits.

Stop - no symptom benefit.

Primary prevention: stop - no symptom benefit.

 

 

 

Drug class 

Prognosis months to weeks
 *Consider that the patient may wish to continue their medicines 

Prognosis days
*Consider that the patient may wish to continue their medicines 

Anticoagulants oral e.g. warfarin, DOACs (rivaroxiban, apixaban, dabigatran, edoxaban). 

Consider indication and review risks vs. benefits.

Stop - no symptom benefit.

 

Anticoagulants injectable e.g. LMWH, fondaparinux.

Prophylactic: continue only if increased VTE risk.

Prophylactic: stop - no symptom benefit.

 

Therapeutic: continue after considering patients QoL.

Therapeutic - stop unless concerns about worsening symptoms.

Peripheral vasodilators e.g. nifedipine.

Review indication - may be used to treat muscle spasm & can provide symptom benefit.

Review. Continue if providing symptom benefit and PO route tolerated.

Dementia e.g donepezil, memantine.

Review benefit. May be appropriate to stop.

Stop - no symptom benefit.

Parkinson’s disease e.g. madopar.

Continue. Symptom benefit. Consider rotigotine TD patch if unable to swallow.

Continue. Consider rotigotine TD patch if unable to swallow (see rotigotine guidance)

Antiepileptics for seizures e.g. levetiracetam, phenytoin, sodium valproate.

Continue. Symptom benefit.

Continue-symptom benefit. Consider switching to SC route &/or midazolam when unable to swallow. See seizure guidance.

Antiepileptics for neuropathic pain e.g. levetiracetam, phenytoin, sodium valproate.

Continue. Symptom benefit.

Review. Continue if providing symptom benefit and PO route tolerated.

Antipsychotics for psychiatric disorder e.g. olanzapine, chlorpromazine, lithium.

Continue. Consider referral to psychiatrist if unsure.

Avoid sudden cessation. Consider alternative drug if PO route lost rapidly. Discuss with psychiatry/ Pall Med if unsure.

Antipsychotics for nausea & vomiting or agitation e.g. haloperidol, levomepromazine.

Continue. Symptom benefit.

Continue. Symptom benefit. Consider alternative route.

Benzodiazepines e.g. lorazepam, diazepam, midazolam and ‘Z’ drugs e.g. zopiclone.

Long term use - continue. Attempt gradual withdrawal if patient wishes. Consider oral diazepam to aid withdrawal.

Short term (agitation &/or seizures) - likely symptom benefit - continue.

Continue. Consider alternative route/formulation.

Antidepressants e.g. SSRIs, mirtazapine, venlafaxine.

Continue for symptom management. Consider gradual withdrawal if deteriorating to pre-empt loss of PO route.

Stop.No symptom benefit.

Thyroid hormones

Continue to avoid hypothyroidism & associated symptoms.

Continue until oral route is lost.

Antihistamines e.g. cetirizine, chlorpheniramine.

Review indication. Continue if providing symptom relief from itch or allergies.

Stop unless providing specific symptom relief & PO route still tolerated.

Vitamin & mineral supplements e.g. calcium, Vit D, B vitamins, iron supplements.

Review indication. Limited benefit except for treatment of low serum concentration. Seek advice if necessary.

 

Stop.No symptom benefit.

Dietary supplements

Review indication. Discuss with patient and team.

Stop unless patient preference. No symptom benefit.

Drug class

Prognosis months to weeks
*Consider that the patient may wish to continue their medicines

Prognosis days
*Consider that the patient may wish to continue their medicines

Steroids e.g. dexamethasone, fludrocortisone, prednisolone.

Continue if still indicated. Ensure CBG monitoring, indication, review & stop date are specified. See steroids and hyperglycaemia guidance.

Review indication - may be appropriate if needed for symptom management & to prevent withdrawal symptoms. Consider alternative route if PO route lost. Seek advice if necessary.

Disease Modifying Anti-Rheumatic Drugs e.g. methotrexate, sulfasalazine.

Review indication. Continue if symptom benefit. Discuss with expert before stopping.

Stop. No symptom benefit.

NSAIDs e.g. naproxen, ibuprofen, diclofenac, ketorolac, paracoxib.

Continue if symptom benefit. Consider ADRs risk vs. benefits.

May be appropriate to continue for symptom management. Consider switching route when oral route is lost e.g. SC ketorolac, paracoxib.

Paracetamol

Continue if clear symptom benefit. Caution in frail - risk of overdosing and tablet burden.

Stop to reduce tablet burden or when PO route is lost.

Opioids e.g. morphine, oxycodone, fentanyl.

Continue. Symptom benefit. See opioid guidance.

Continue. Symptom benefit. Consider alternative route. See opioid guidance.

Neuropathic drugs e.g. gabapentin, pregabalin, amitriptyline.

Continue. Symptom benefit.

Continue until oral route is lost. Symptom benefit.

Alpha reductase inhibitors for urinary symptoms e.g. finasteride, oxybutynin, solifenacin, tamsulosin.

Continue. May provide symptom benefit. Discontinue if catheter in situ.

Review indication. Continue for painful bladder spasm until oral route lost. Consider stopping for prostatic symptoms.  

Inhaled steroids e.g. beclomethasone, fluticasone.

Continue may provide symptom benefit. See LTHT COPD guidance. Check able to use current inhalers

Stop. Unlikely to be of benefit in last days.

Other inhalers e.g. salbutamol, salmeterol, tiotropium.

Continue may provide symptom benefit. See LTHT COPD guidance. Check able to use current inhalers

Review. Continue only if patient still able to use and benefit.

Theophylline

Continue -may provide symptom relief but requires monitoring.

Stop. Unlikely to be of benefit in last days.

Drops, sprays, ointments, creams e.g. moisturisers, eye drops, nasal drops.

Review indication & continue if symptom benefit.

Review. Continue only if patient still able to use and benefit.

Antibacterials

Review indication & continue if for acute symptom benefit. Ensure indication, review & stop date are specified.
Cease prophylactic antibiotics.

Consider carefully. Unlikely to be appropriate but used occasionally for symptom management at the end of life.

Antifungals

Review indication & continue if symptom benefit. Ensure indication, review & stop date are specified.

Oral thrush - considering continuation as may provide symptom benefit. Systemic fungal infection - consider stopping. Unlikely to provide symptom benefit.

References

  • Scottish Government Polypharmacy Model of Care Group (2018) Scottish Polypharmacy Guidance - Realistic Prescribing 3rd ed, 2018
  • Lavan A et al (2017) STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age and Ageing 2017; 46: 600-607

Resources

Leeds Health Pathways

Others

Measuring effectiveness of deprescribing:

  • Improvements in drug utilisation may be reflected in an overall reduction in:
  • GI bleeds, bleeding of any cause, HF, AKI, falls & fractures, stroke, delirium, C Difficle infection, hypoglycaemia, hyperglycaemia, hyperkalaemia
  • Waste management - cost savings - statins, antihypertensives, NSAIDs, vitamins and minerals, bisphosphonates and gastroprotective agents

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