Hello, deprescribers! Today we have another interview blog post with Dr. Petra Denig, Professor at the University of Groningen, telling us about the development of deprescribing recommendations for the Dutch multidisciplinary guideline on polypharmacy in older people.
Q: This week, the Dutch national guideline with recommendations for deprescribing was made publicly available. First off, can you tell us a little bit about the background for developing this guideline?
Petra: Well, in the Netherlands, medication reviews have to be conducted for elderly people with polypharmacy. General practitioners and community pharmacists, who have to conduct these medication reviews, sometimes struggle with stopping medications and have expressed the need for more explicit guidance. When it was time to revise our Dutch multidisciplinary guideline, ‘Polypharmacy in the Elderly’, the Dutch professional organizations involved in this revision decided to include a part about deprescribing.
Q: How was the deprescribing guideline developed? Which medication classes does the guideline cover and why were these selected as topics?
Petra: The AGREE instrument was used for the development and nine stakeholder organizations, as well as independent experts, were involved. The guideline itself includes a general part with recommendations on how and when to conduct deprescribing and separate chapters summarizing the evidence on deprescribing of specific drug classes. For the general part, particular attention is being paid to how to involve patients and the multidisciplinary approach needed. For the separate chapters, 10 initial drug classes were selected, for which it was expected that deprescribing can be beneficial in elderly or vulnerable patients. These include anticoagulants, platelet aggregation inhibitors, antihypertensives, diabetes drugs, statins, bisphosphonates, calcium & vitamin D, proton pump inhibitors, and several urologicals. In the future, other drug classes will be added.
Q: How do you expect the uptake of the recommendations will be in the Netherlands? Can you tell us about any implementation or dissemination efforts?
Petra: The guideline has been endorsed by national organizations of community pharmacists, hospital pharmacists, general practitioners, medical specialists, and by the Dutch patient federation. Recommendations for implementation are included in the guideline and several initiatives have already started. There are training modules for healthcare providers, including an e-learning package for general practice and a program to be used in pharmacotherapy counseling groups. Most Dutch general practitioners and community pharmacists participate in these counselling groups. Also, the deprescribing recommendations will be incorporated in the future updates of related national disease-specific practice guidelines. Furthermore, some recommendations will be included in a national website to inform patients about stopping medications.
Q: From your point of view as a researcher or pharmacist, what are some of the key areas of focus for deprescribing in the older population?
Petra: I want to focus on proactive deprescribing of cardiovascular and diabetes drugs in this population. These drugs contribute to medication problems in older people, which can be avoided by timely dose reductions or stopping of drugs. Actually, we have already started with pilot studies to test pharmacist-led interventions to reduce such medication, within the so-called DISCARDt consortium (in Dutch only). We have conducted focus groups to identify barriers and enablers to deprescribing of cardiometabolic drugs, and developed an algorithm to select patients for an intervention. Some findings have recently been published by one of our PhD students, Stijn Crutzen, and we hope to publish further results next year.
Q: Last but not least: What is the most satisfying deprescribing target that your team made recommendations for?
Petra: I am really happy that we made recommendations on how to involve patients in the process of deprescribing, particularly the recommendations to first explore the views and experiences of the individual patients towards the use of their medication before talking about stopping, and then to prioritize which medication to stop together with the patient. Also, the recommendation to make a clear stepwise plan on how to stop, including monitoring and the option to restart, is important for the patient’s willingness to participate in deprescribing.
If you have any questions for Petra, you can reach her via email: firstname.lastname@example.org. You can also find more information about the Dutch deprescribing guideline here (in Dutch only): https://www.nhg.org/actueel/nieuws/nieuwe-module-bij-mdr-polyfarmacie-bij-ouderen-minderen-en-stoppen-van-medicatie