Welcome to our 7th guest blog post. Today, we have Dr. Nagham J. Ailabouni from the University of South Australia writing about deprescribing during the COVID-19 pandemic. Take it away!
COVID-19 and older adults
The coronavirus disease (COVID-19) pandemic has affected almost 8 million people and resulted in nearly 5 million deaths worldwide. Older adults are disproportionally affected by COVID-19 and have a higher risk of complications due to preexisting comorbidities. Managing multimorbidity and associated polypharmacy has become even more complicated during this pandemic. Clinicians are working relentlessly to control and treat COVID-19 at the frontlines and some have developed resources to help guide the appropriate treatment of older adults during this time.
Hydroxychloroquine in the context of other medication-related problems in older adults
Hydroxychloroquine and chloroquine have received much attention in the media. The jury is still out on whether these medications are effective as COVID-19 treatment/prophylaxis. Regardless, being aware of potential drug-drug interactions with these medications is important in older adults, particularly because the pharmacokinetic profile of these and other potential COVID-19 medications differ in this population. Further, it is important to consider hydroxychloroquine in the context of polypharmacy and potentially inappropriate medication (PIM) use that is so common in older adults.
The COVID-SAFER trial aimed to quantify the degree of polypharmacy and burden of PIMs that could interact with hydroxychloroquine.
By re-analyzing data of 1001 hospitalized older adults collected from a previous study (MedSafer), Ross et al. found that more than half (58.9%) of older adults were receiving one or more medications that could interact with hydroxychloroquine; almost half of these (43.2%) were potentially inappropriate. This means that even if hydroxychloroquine is effective for COVID-19, over half of hospitalized older adults would not be able to take it without being exposed to additional risk. But, through deprescribing of interacting PIMs, the proportion of those affected would be halved. Medication classes commonly implicated included selective serotonin/norepinephrine reuptake inhibitors, antipsychotics, antiarrhythmics (digoxin, amiodarone) and anti-diabetic medications (insulin, sulfonylureas). Risk of QTc prolongation and resulting in sudden death from torsade de pointes was the most serious interaction identified.
Drug-drug interactions and the use of PIMs on their own are associated with an increased risk for developing adverse drug events (ADEs). So, given the poor prognosis many older adults with COVID-19 face, reducing their exposure to such medications could decrease the likelihood of further complications.
Where does deprescribing fit in?
While deprescribing has been encouraged as an approach by some, others debate that “unless there is clear evidence to support an urgent change to patients’ medicines, deprescribing should wait until the pandemic is over”. The COVID-SAFER trial shows that achieving optimized medication regimens should be a priority for older adults at all times but possibly even more so during a pandemic when healthcare resources are already stretched. With that being said, considering the appropriate stage/time to introduce deprescribing and which medications to target first should be made in accordance with the needs and health goals of each individual.
Ross et al. found that there is room for improvement. Half of the PIMs the authors identified were a potential deprescribing target. These authors discuss several deprescribing opportunities to consider, including:
- Reducing the dose of digoxin in patients with poor renal function
- Avoiding the use of antipsychotics in patients with risk of delirium
- Reducing the use of insulin and deprescribing sulfonylureas in older adults at risk of hypoglycemia or who have tight glycemic control (HbA1C <7.5%) alongside glucose monitoring
- Monitoring QTc and electrolytes in older adults prescribed QTc prolonging agents
We must acknowledge that deprescribing during COVID-19 is no easy feat. Elbeddini et al. summarize deprescribing barriers present in the healthcare system prior to the pandemic and further add barriers that are present when trying to implement deprescribing during the age of COVID-19. These include the challenges for older adults in using technology (impacting accessibility to telehealth), lack of health literacy and lack of assistance from others (potentially worsened by self-isolation and lockdown measures).
As always, striving to continuously review medication lists to ensure they are up-to-date and appropriate can reduce the likelihood of medication harm and resulting ADEs in older adults. Deprescribing inappropriate medications, whenever possible, could result in a ripple effect of potentially less serious complications and a swifter recovery of older adults with COVID-19.