With Dr. Ellen Middendorf
Classes of Medications
In this months Medical Minute, we will begin to dive into which classes of medications should be on the hot seat for removal/deprescribing. In other words, what types of medications lose their luster or purpose as we enter end-of-life care. Hospice care is about palliating symptoms and improving quality of life once the patient has opted to discontinue aggressive treatment for his/her life-limiting illness. Thus, medications aimed at prevention, slowing progression or those with concerning current or possible side effects are of utmost priority.
The following classes of medication deserve review in all patients admitted to hospice:
- Respiratory hand-held inhalers
- Cholesterol medications
- Dementia medications
- Proton pump inhibitors, for example omeprazole (Prilosec)
- Diabetes medications
- Appetite stimulants
Respiratory Hand-held Inhalers
Hand-held respiratory inhalers are a mainstay of treatment for asthma, COPD, chronic bronchitis and emphysema. Patients rely on these inhalers to quickly relieve shortness of breath and wheezing. However, as respiratory disease advances, patients lose their ability to adequately inhale the medication, hold their breath and slowly exhale, all components of successful use. Without this technique, the medication often sits in the mouth or the back of the throat and does not reach the lower respiratory tract where it is needed. This process also requires hand-mouth coordination and mental acuity. Thus, severe arthritis or cognitive impairment can limit use as well. In addition to medication failure and lack of benefit, inhaled steroid medications can cause thrush (oral yeast infection) if left deposited in the mouth.
To ensure the most adequate response to these medications that open the airways, we often suggest discontinuing hand-held inhalers and transitioning to nebulizer delivery. This method allows the patient to inhale the medication through an aerosolized mist via a face mask. This requires no special coordinated breathing and ensures that the medication reaches the lower airway tract.
Anticoagulants, often known as “blood thinners”, are used to treat an actual blood clot. They are prescribed to reduce the chance of a clot forming in response to certain medical conditions, like atrial fibrillation. Inherent in their nature, by thinning the blood, they increase the risk of bleeding. Thus, if a patient is at risk for falling, the risk of a major bleeding event caused by a potential fall must be weighed against the risk of a possible or actual clot. The patient’s liver and kidney function must also be considered. These comorbidities can increase the risk of bleeding in and of themselves. While complicated, targeted education and discussion help make educated decisions.
Cholesterol-lowering medications reduce the long-term risk of cardiovascular and cerebrovascular disease. The most common group of these medications is the “statins”. A randomized clinical trial determined the outcome of describing these medications in a population of patients with a life-limiting illness. Completed in 2014, the study by Abernethy et al, showed that the subset of patients that stopped their “statin” had a better quality of life than those that continued the medication. Common side effects of these medications include muscle pain and weakness and gastrointestinal distress. Therefore, cholesterol medications have very limited utility in end-of-life care.
Dementia medications slow the progression of mild to moderate cognitive dysfunction. These medication examples include donepezil (Aricept) and memantine (Namenda). If a patient has entered hospice care due to his/ her dementia, the disease is certainly beyond the moderate stage. The disease has also progressed despite the patient being on these medications; therefore, their usefulness is no longer evident. These medications also increase the risk of falls, gastrointestinal distress, fainting and low heart rate. Thus, typically, these medications lack benefit in end-of-life care.
In summary, for these classes of medications mentioned above, the healthcare provider and the patient/family must consider the desired intention of the medication and the patient’s current physical and mental state. If the two do not align, then a thoughtful deprescribing process should begin.