Marion V.N. Stanley, MD

Clinical question: Among older adults, what attitudes exist toward deprescribing?

Background: Polypharmacy in older adults is common and can be associated with increased hospitalizations and reduced quality of life.

Study design: Population-based survey study.

Setting: Medicare beneficiaries in the United States.

Synopsis: The investigators used data from the National Health and Aging Trends Study (NHATS), which collects information annually on a nationally representative sample of Medicare beneficiaries ages 65 and older. Of 1,981 responses on the NHATS Medication Attitudes module, 92% of older adults expressed willingness to stop a medication if their doctor said it was possible. While 89% agreed that all their medications were necessary, 66.6% also agreed that they would like to reduce the number of their medications. Patients taking more than six medications, compared with those taking fewer than six (adjusted odds ratio, 2.9; 95% confidence interval, 1.74-4.82) and those with three or more medical conditions, compared with patients with fewer than two (aOR 2.87; 95% CI 1.53-5.37) had greater odds of willingness to stop a medication. Importantly, the study did not collect data about specific medications.

Bottom line: A vast majority of older adults would be willing to stop one or more of their medications if considered possible by their physician, and two-thirds want to reduce the number of their medications. If appropriate, hospitalists should consider having a conversation about deprescribing with their older patients.

Citation: Reeve E et al. Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. JAMA Intern Med. 2018;178(12):1673-180.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Among older adults, what attitudes exist toward deprescribing?

Background: Polypharmacy in older adults is common and can be associated with increased hospitalizations and reduced quality of life.

Study design: Population-based survey study.

Setting: Medicare beneficiaries in the United States.

Synopsis: The investigators used data from the National Health and Aging Trends Study (NHATS), which collects information annually on a nationally representative sample of Medicare beneficiaries ages 65 and older. Of 1,981 responses on the NHATS Medication Attitudes module, 92% of older adults expressed willingness to stop a medication if their doctor said it was possible. While 89% agreed that all their medications were necessary, 66.6% also agreed that they would like to reduce the number of their medications. Patients taking more than six medications, compared with those taking fewer than six (adjusted odds ratio, 2.9; 95% confidence interval, 1.74-4.82) and those with three or more medical conditions, compared with patients with fewer than two (aOR 2.87; 95% CI 1.53-5.37) had greater odds of willingness to stop a medication. Importantly, the study did not collect data about specific medications.

Bottom line: A vast majority of older adults would be willing to stop one or more of their medications if considered possible by their physician, and two-thirds want to reduce the number of their medications. If appropriate, hospitalists should consider having a conversation about deprescribing with their older patients.

Citation: Reeve E et al. Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. JAMA Intern Med. 2018;178(12):1673-180.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Among older adults, what attitudes exist toward deprescribing?

Background: Polypharmacy in older adults is common and can be associated with increased hospitalizations and reduced quality of life.

Study design: Population-based survey study.

Setting: Medicare beneficiaries in the United States.

Synopsis: The investigators used data from the National Health and Aging Trends Study (NHATS), which collects information annually on a nationally representative sample of Medicare beneficiaries ages 65 and older. Of 1,981 responses on the NHATS Medication Attitudes module, 92% of older adults expressed willingness to stop a medication if their doctor said it was possible. While 89% agreed that all their medications were necessary, 66.6% also agreed that they would like to reduce the number of their medications. Patients taking more than six medications, compared with those taking fewer than six (adjusted odds ratio, 2.9; 95% confidence interval, 1.74-4.82) and those with three or more medical conditions, compared with patients with fewer than two (aOR 2.87; 95% CI 1.53-5.37) had greater odds of willingness to stop a medication. Importantly, the study did not collect data about specific medications.

Bottom line: A vast majority of older adults would be willing to stop one or more of their medications if considered possible by their physician, and two-thirds want to reduce the number of their medications. If appropriate, hospitalists should consider having a conversation about deprescribing with their older patients.

Citation: Reeve E et al. Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. JAMA Intern Med. 2018;178(12):1673-180.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Synopsis: Among 814,049 patients aged 65 years and older with high-risk medical conditions, 9.3% were prescribed NSAIDs. Of those prescribed NSAIDS, a vast majority had only HTN (90.8%). There was substantial variation in NSAID prescriptions among physicians (range 0.9%-69.2%; median, 11%). During the study period, there was a decline in the frequency of NSAID prescriptions. Those patients with reduced odds to receive an NSAID prescription had CKD, HF, hospitalization in the past year, or prior opiate use. Of 35,552 matched patient pairs either exposed or not exposed to NSAIDs (not controlled for disease severity), there was a similar rate of cardiac complications (288 vs. 279), renal complications (34 vs. 33), and death (27 vs. 30).

Patients with current opiate prescriptions were excluded. This study did not capture those patients taking ASA, over-the-counter formulations or topical NSAIDs.

Bottom line: NSAIDs are frequently prescribed among older adults with high-risk conditions, and short-term use of NSAIDs was not associated with increased cardiovascular or renal safety–related outcomes in this study. In otherwise healthy patients with HTN and musculoskeletal pain, it might be reasonable to trial a short course of NSAIDs with close monitoring.

Citation: Bouck Z et al. Frequency and associations of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease. JAMA Intern Med. 2018 Nov;178(11):1516-25.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Synopsis: Among 814,049 patients aged 65 years and older with high-risk medical conditions, 9.3% were prescribed NSAIDs. Of those prescribed NSAIDS, a vast majority had only HTN (90.8%). There was substantial variation in NSAID prescriptions among physicians (range 0.9%-69.2%; median, 11%). During the study period, there was a decline in the frequency of NSAID prescriptions. Those patients with reduced odds to receive an NSAID prescription had CKD, HF, hospitalization in the past year, or prior opiate use. Of 35,552 matched patient pairs either exposed or not exposed to NSAIDs (not controlled for disease severity), there was a similar rate of cardiac complications (288 vs. 279), renal complications (34 vs. 33), and death (27 vs. 30).

Patients with current opiate prescriptions were excluded. This study did not capture those patients taking ASA, over-the-counter formulations or topical NSAIDs.

Bottom line: NSAIDs are frequently prescribed among older adults with high-risk conditions, and short-term use of NSAIDs was not associated with increased cardiovascular or renal safety–related outcomes in this study. In otherwise healthy patients with HTN and musculoskeletal pain, it might be reasonable to trial a short course of NSAIDs with close monitoring.

Citation: Bouck Z et al. Frequency and associations of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease. JAMA Intern Med. 2018 Nov;178(11):1516-25.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Synopsis: Among 814,049 patients aged 65 years and older with high-risk medical conditions, 9.3% were prescribed NSAIDs. Of those prescribed NSAIDS, a vast majority had only HTN (90.8%). There was substantial variation in NSAID prescriptions among physicians (range 0.9%-69.2%; median, 11%). During the study period, there was a decline in the frequency of NSAID prescriptions. Those patients with reduced odds to receive an NSAID prescription had CKD, HF, hospitalization in the past year, or prior opiate use. Of 35,552 matched patient pairs either exposed or not exposed to NSAIDs (not controlled for disease severity), there was a similar rate of cardiac complications (288 vs. 279), renal complications (34 vs. 33), and death (27 vs. 30).

Patients with current opiate prescriptions were excluded. This study did not capture those patients taking ASA, over-the-counter formulations or topical NSAIDs.

Bottom line: NSAIDs are frequently prescribed among older adults with high-risk conditions, and short-term use of NSAIDs was not associated with increased cardiovascular or renal safety–related outcomes in this study. In otherwise healthy patients with HTN and musculoskeletal pain, it might be reasonable to trial a short course of NSAIDs with close monitoring.

Citation: Bouck Z et al. Frequency and associations of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease. JAMA Intern Med. 2018 Nov;178(11):1516-25.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.