Manage the Prescribing & Cancellation Process
Dr. Chrostowski said that de-prescribing is such an important aspect of care for some patients that the very definition of prescribing should be reconsidered.
“We’ve always kind of thought of prescribing as adding more medications,” she said. “Prescribing should be an overall umbrella concept of how we’re managing all of [a patient’s] prescriptions. It could involve eliminating some medications, adjusting doses on others.”
The START (Screening Tool to Alert Doctors to Right Treatment) tool is a way to evaluate a patient’s medication list, with a focus on physiologic symptoms, providing information on the cardiovascular, gastrointestinal and central nervous systems and considerations for pharmacy for each system. It is rooted in evidence-based rules for avoiding commonly encountered examples of inappropriate prescribing and potential screening omissions.
The STRIP (Systematic Tool to Reduce Inappropriate Prescribing) tool is another systematic way to manage the prescribing and de-prescribing process, incorporating patient preferences.
“You actually look at [the patient’s] drug history, analyze the drugs they’re taking and come up with a treatment plan,” Dr. Chrostowski said. “You really have to have the patient on board to make any kind of medication changes.”
The de-prescribing process can run into hurdles: Some therapies are recommended by guidelines. There can be concern about withdrawal side effects. Some prescriptions may have been initiated by another provider. There may not be enough time to go through the process. Patients themselves may resist getting off medications, despite the added simplicity and lower cost related to taking fewer drugs.
“We like to think patients are going to be willing to get off medications and reduce their drug costs—and a lot of times that is the case, but not always,” Dr. Chrostowski said. “It may take several efforts. You may have to really have some discussions about the reasons behind this [and] the concerns about their long-term health.”
Thomas R. Collins is a freelance writer living in South Florida.
References
- Bechman K, Clarke BD, Rutherford AI, et al. Polypharmacy is associated with treatment response and serious adverse events: Results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatology (Oxford). 2019 Oct 1;58(10):1767–1776.
- Kaiser Family Foundation. Retail prescription drugs filled at pharmacies per capita: 2018. https://www.kff.org/health-costs/state-indicator/retail-rx-drugs-per-capita/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
- Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: Results of an international, cross-sectional study (COMORA). Ann Rheum Disease. 2014 Jan;73(1):62–68.
