Everyday there are more news headlines about policymakers addressing different approaches to lowering healthcare and prescription drug costs.
This spring alone saw news about the approval of the second gene therapy Zolgensma (onasemnogene abeparvovec-xioi), a one-time treatment for spinal muscular atrophy (SMA) affecting about 1 in 11,000 babies, with pricing set at $2.1 million, making it the most costly drug on the market. Additionally, Luxturna (voretigene neparvovec-rzyl), the first approved gene therapy to treat vision loss from biallelic RPE65 mutation-associated retinal dystrophy affecting 1 in 2,000 people in the U.S., is set at $425,000 per eye.
The therapeutics market is rapidly changing with the introduction of these kind of cutting-edge, high-end therapies for a limited number of patients, compared to widespread, generally available therapies for people suffering from a number of chronic diseases. This made me ask the question: Could deprescribing be a tool that could address lowering healthcare and prescription drug costs if more widely used?
Deprescribing is the planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden or harm while improving quality of life. The practice of deprescribing often targets patients with multiple chronic conditions, who are elderly, or who have a limited life expectancy. In these situations, medications may contribute to an increased risk of adverse events, and people may benefit from a reduction in their medication burden.
The process can be difficult, whether in clinical medicine or health policy. In a 2017 commentary, physicians described deprescribing as “swimming against the tide” of patient expectations, the medical culture of prescribing, and organizational constraints.
Deprescribing has been shown to result in fewer medications with no significant changes in health outcomes. A systematic review of deprescribing studies for a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, concluded that adverse effects of deprescribing were rare.
Potential benefits of deprescribing
A recent study among cancer patients showed that a lack of deprescribing resulted in many being prescribed preventive medications at the end of their lives that may harm their quality of life while providing questionable clinical benefits. The study showed that the median drug costs during the last year of life were $1,482 per individual, including $213 for preventive therapies. Approximately one-fifth of the total costs of prescribed drugs were for preventive medicines. This proportion only decreased slightly as death approached.
A physician in practice who takes time during their busy day to examine a patient’s medications or enlist the pharmacist to provide comprehensive medication review as part of their deprescribing toolkit can make a difference in patient outcomes and costs. A number of tools have been developed to support the deprescribing process, including those available from the Bruyère Research Institute at deprescribing.org/resources/deprescribing-guidelines-algorithms.
The most common deprescribing algorithm may be accessed here: www.ncbi.nlm.nih.gov/pmc/articles/PMC4778763/figure/pone.0149984.g001. It has been validated and tested in two randomized controlled trials. The algorithm prompts clinicians to consider:
- Whether a medication is an inappropriate prescription
- If adverse effects or interactions outweigh symptomatic effect or potential future benefits
- If it’s taken for symptom relief but the symptoms have stabilized
- Whether it is intended to prevent serious future events, but limited life expectancy may temper potential benefit
If the answer to any of the four prompts is yes, then the medication should be considered for deprescribing.
The process is remarkably similar to the IESA process: indication, effectiveness, safety, and adherence. That process is part of the Patient Care Process for Delivering Comprehensive Medication Management. The Comprehensive Medication Management Research Team notes in this guidance that, “The integration of clinical services focused on optimizing medication use into patient care may help primary care providers, specialists, and other members of the healthcare team meet the quadruple aims of improving population health, increasing patient satisfaction, reducing per-capita healthcare costs, and addressing provider satisfaction. Comprehensive medication management (CMM) holds promise as a key strategy for meeting these goals.”
While conducting CMM for patients can provide key benefits, how that is done in a busy outpatient/community pharmacy environment can vary with different infrastructures set up and team roles. As a front-line practitioner, I began to think if there might be additional information or tools that could be added to my suite of drug information tools/monographs that would indicate evidence for deprescribing in certain populations. Such tools or data could help me make a decision through the regular workflow DUR process to medication recommendations to the patient’s physician or to refer the patient to the appropriate pharmacist in my organization for a CMM. Having access to quick, reliable, evidence-based information might help me become a more frequent contributor to the deprescribing process with the potential to lower costs and improve outcomes.
Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.
