In the final article of our series on “deprescribing, why should I stop that medication?”, we will continue to review medication classes that warrant a hard look upon transitioning into hospice care. In review, deprescribing is a proactive process to remove medications that have no fruitful indication for use, lack benefit or have the potential to cause adverse effects.
Why Stop That Medication: Diabetes Medication
We will begin the discussion with diabetes medication. The ADA (American Diabetes Association) has released the following guidance, “For patients receiving palliative care and end-of-life care, the focus should be to avoid hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management.” Contrary to other times in life, the goal blood sugar is safely set at 200-300 mg/dL. Patients at end-of-life are less likely to benefit from reducing the risk of diabetes complications, such as eye and kidney disease.
As oral intake varies and ultimately declines, blood sugar can often become labile. If the patient is asymptomatic, caregivers should heavily weigh the need to check blood sugars, as the process does involve a pinprick and induces mild discomfort. Deprescribing of diabetes medications is often the most emotionally charged of all the deprescribing discussions. Patients have been educated by their medical providers, typically for many years, on the importance of strict glycemic control; however, as hospice providers, we must now educate as well on the very real risk of low blood sugar and the ability to relax the strict standards at this time in their life. The process often begins by eliminating the medications at highest risk to cause hypoglycemia and then continue to reevaluate the lower risk medications over time as the hospice care team-patient relationship develops.
Multiple types of medications are used as appetite stimulants, including steroids, antidepressants, hormonal agents and cannabinoids. All these medications have short-term and long-term side effects, some more serious than others. Thus, this is truly a balancing act of risk versus benefit. Is the patient gaining weight while on the medication? Even if they are gaining weight, is it improving his/her quality of life? Remember, the goal should always be quality of life, not solely a number. The act of eating and sharing a meal with family and friends is a very emotional experience. Loved ones often have the most difficult time with this lost activity. For more information on this topic, please review May’s Medical Director Minute, “Mom’s not eating much anymore”.
Proton pump inhibitors, for example, omeprazole (Prilosec)
Now let us discuss a group of medications called “Proton Pump Inhibitors”. This class includes the common medication, omeprazole (Prilosec). This group of medications is commonly overused and often continued long-term despite the recommendation to use for a discrete amount of time, except in a few special circumstances. These medications are often started while a patient is in the hospital for gastric protection, and then, due to transitions in care, are never discontinued. Prolonged use of these medications can increase the risk of hip fractures, poor vitamin B12 and magnesium absorption and Clostridioides colitis (formerly known as C diff). We certainly do not want our patients to suffer uncontrolled heartburn or gastric upset; therefore, a thorough symptom review must occur, and consideration should be given to other agents also useful for treating these symptoms.
Finally, an encompassing review should be given to all over-the-counter medications, vitamins and supplements. These products often have significant interactions with prescription medications. They also contribute to the overall pill burden. As appetite decreases, taking multiple pills contributes to a feeling of satiety. Pills are often taken with less food and liquid during end-of-life, due to overall decreased oral consumption and/or swallowing difficulties. This contributes to nausea and vomiting. Medical studies on most supplements are minimal regardless, and their use should be strongly reviewed at end-of-life.
Now You Understand Why To Stop That Medication, Especially In End-Of-Life Care
Hospice of Southern Illinois’ care team conducts deprescribing medications. The Hospice Medical Director, Associate Medical Directors and our full-time pharmacist lead the full medication review. We are aware that deprescribing can be an emotional process. Rest assured, we have your goals of care top-of-mind and best interests at heart.