Jennifer Good MDHospice Medical Director, Home Nursing

AgencyAltoona, Pennsylvania

Mary Mihalyo BS, PharmD, RPhDuquesne University

Pittsburgh , Pennsylvania

ObjectivesTo understand that many medications that

patients are on for chronic illnesses may not be helpful late in life.

To understand that decisions for discontinuation must be individualized and take into consideration the patient’s goals of therapy, life expectancy and risk/benefits of discontinuation (will depend on comorbidities).

To understand that there is little experimental data dictating discontinuing medications in palliative care patients.

Elizabeth N.Elizabeth N. is a 90 y/o woman who has been referred

to hospice following three hospitalizations in the last 2 months for refractory congestive heart failure. She is short of breath with minimal exertion. She has decided that she does not want to be readmitted to the hospital.

Her current medications include furosemide, lisinopril, carvedilol, spironolactone, warfarin, simvastatin, ASA, alendronate and morphine sulfate PRN.

Would it be appropriate to discontinue any of these medications?

Specific considerations in discontinuing medicationsLife-expectancy

What is patient’s life expectancy?How long does it take to see a benefit from a

given drug?Risk/benefit ratios

For general populationFor given patient

Patient’s goals of therapyTreatment targets (what is the treatment for)

Life-expectancy?Palliative Care vs. Hospice Care

Expected life expectancy in hospice is < 6 months

Expected life expectancy in palliative patients with multiple chronic co-morbidities might be 12 months or more

How long to see effect from prescribed medication?How long does it take for medication to

render effect?Analgesics—minutes to hoursBisphosph0nates for osteoporosis—months to

yearsTight glucose control in DM—yearsStatins?

Risk-benefit ratio?Benefits for general population

NNTBenefits for given patient

Controls symptomsHarms for general population

NNHHarms for a given patient

Adverse drug reactionsCostTreatment is not in line with overall goals of

care

Patient’s goals of therapy?Prolong lifePrevent morbiditySlow disease progressionPrevent declineComfort

Treatment targets?Primary preventionSecondary preventionControl chronic diseasesTreat acute diseasesControl symptoms

Medications to consider discontinuingCholesterol lowering therapyAnti-platelet agentsAnti-coagulantsDementia medicationsOsteoporosis medications

Discontinuing statinsWhat is risk of ACS or CVA upon

discontinuing?ACS

Prevent 5 MIs in 100 patients treated for 5 years (secondary prevention)

Decreased risk of death by 20 – 30% over 5 years Patients have increased mortality if statin

discontinued during ACS (5% vs. 11%) Immediate risk reduction—1 less MI in 100 patients

treated for one month after MI.CVA

Recommendations for discontinuing statinContinue:

Recent MIRecent CVA? Symptoms of myocardial ischemia

Discontinue:Patients on statin for primary prophylaxis

Anti-platelet AgentsAspirin

Clopidogrel (Plavix ®)/Prasugrel (Effient®)

ASA/Dipyridamole (Aggrenox ®)

Discontinuing anti-platelet agentsContinue clopidogrel/ASA if:

Bare metal stent in last 3 monthsDrug-eluting stent in last 12 monthsRecent TIA/CVA (if occurred while patient on ASA)

Continue Aggrenox® if:Recent TIA/CVA (if occurred while patient on ASA)

Continue ASA if:Used for secondary prevention in patients with h/o

ACS or CVAUsed for primary prevention in high risk patientRecommend 81 mg/d

AnticoagulantsWarfarin—most common indications:

Chronic Atrial Fibrillation to prevent thromboembolic complications

Mechanical heart valves to prevent valve thrombosis and thromboembolic complications

Patients with history of venous thromboemboli (VTE)

Dabigatran—a new oral direct thrombin inhibitorNon-valvular chronic Atrial Fibrillation

Low molecular weight heparinsMost commonly used long term in patients with

VTE and concomitant malignancy

Risk of Embolic Events in AFRisk is 2 – 18% yearRisk based on

CHAD2 score:Low risk = 0Moderate = 1 High risk= ≥ 2

CHAD2 Score Stroke Risk %)1

0 1.9

1 2.8

2 4.0

3 5.9

4 8.5

5 12.5

6 18.5

1 Gage BF. JAMA 285(22):2864 – 70.

Recommendation for Discontinuing Warfarin/DabigatranContinue in Atrial Fibrillation if:

CHADs2 score of 5 – 6Prior CVAMechanical valve (particularly if

mitral/tricuspid position)Continue in VTE if:

VTE in last 3 – 6 months History of recurrent VTEVTE with concomitant malignancy (LMWH is

probably first choice as more efficacious)

Dementia medicationsCholinesterase inhibitors—indicated for mild

to moderate dementiaDonepezil (Aricept®)Rivastigment (Exelon®)Galantamine (Razadyne®)

NMDA receptor antagonist—indicated for moderate to severe dementiaMemantine (Namenda®)

Recommendations for discontinuing dementia medicationsPatients in hospice have dementia more

severe than what drug therapy is indicated for

Expensive$200 – 300/month

May be safer to taperCan see more agitation when medication

discontinuedAlternative, cheaper agents for agitation exist

Osteoporosis MedicationsBisphosphonates

Alendronate (Fosamax ®)Risedronate (Actonel®)Ibandronate (Boniva®)Zoledronic Acid (Reclast®)

Teriperatide (Forteo®)≈ $1000/month

Recommendations for discontinuing osteoporosis medicationsContinue bisphosphonates if:

Known metastatic bone diseaseBreast CA, prostate CA or multiple myelomaPaget’s disease of bone (usually high dose)

Discontinue all other osteoporosis medications:TeriperatideDenosumab (Prolia®)CalcitriolCalcitonin?

Drugs to taper if discontinuingAnti-epileptic medicationsOpioidsAnti-depressantsBenzodiazepinesBeta blockersClonidineCorticosteroids

Barriers to discontinuing medicationsPsychological attachmentConcern that discontinuation implies “giving

up”Uncertain of risks with discontinuationPhysical dependenceClinical inertiaPoor communication

Elizabeth N.Elizabeth N. is a 90 y/o woman who has been referred

to hospice following three hospitalizations in the last 2 months for refractory congestive heart failure. She is short of breath with minimal exertion. She has decided that she does not want to be readmitted to the hospital.

Her current medications include furosemide, lisinopril, carvedilol, spironolactone, warfarin, simvastatin, ASA, alendronate and morphine sulfate PRN.

Would it be appropriate to discontinue any of these medications?

Elizabeth N.Discontinue:

WarfarinSimvastatinAlendronate

Continue:LisinoprilCarvedilolSpironolactoneASAMorphine sulfate

David E.David E. is a 53 y/o referred to hospice with newly

diagnosed metastatic pancreatic cancer. At the time of presentation his tumor was non-resectable due to hepatic metastases and a biliary stent was placed percutaneously because of obstructive jaundice. His comorbidities include COPD, BPH and a DVT which occurred during his recent hospitalization.

His current medications include warfarin, tamsulosin, ipratropium, salmeterol/fluticasone, saw palmetto, iron sulfate and oral meperidine for pain.

David E.Discontinue

Saw palmettoFeSO4Meperidine (substitute alternative opioid)

ContinueTamsulosinIpratropiumSalmeterol/fluticasoneWarfarin (consider change to LMWH)

Lola P.Lola P. is a 89 y/o woman with endstage

dementia who has been referred to hospice. She is nonambulatory, nonverbal, is unable to assist in any activities of daily living. She is incontinent and has contractures of her hands and knees. Her comorbidities include COPD, CAD (with prior MI and CHF), HTN and hypercholesterolemia.

Her current medications include furosemide, lisinopril, salmeterol/fluticasone, simvastatin, alendronate, vitamin D, calcium carbonate, omeprazole, donepezil, memantine and aspirin

Lola P.Discontinue

Vitamin DCalcium carbonateSalmeterol/fluticasone (substitute PRN nebulized

beta agonist)DonepazilMemantineSimvastatinAlendronate

ContinueFurosemideLisinopril(? Omeprazole)

Jennifer Good, MDjgood@altoonafp.org

Mary Mihalyo, BS, PharmDMihalyo@duq.edu