A family doctor sent a 40-year-old woman to Sadie Quintal, a primary care clinical pharmacist with the Comox Valley Primary Care Network in British Columbia, because the woman had specifically asked for help in reducing her medications. The woman was about five feet and seven inches tall and weighed around 360 pounds. Her weight had become increasingly troubling for her. Several of the medications she’d been prescribed were known to cause weight gain, so she hoped by taking less, she might be able to lower her weight and better her health.
Regular MedShadow readers are likely familiar with the idea of deprescribing—the process of reducing the number or dose of drugs a person is taking. MedShadow has written about the phenomenon before. But, while the idea of taking fewer medications is simple, the real world process of deprescribing, while balancing risks versus benefits, is complicated. Some medications have withdrawal symptoms, and tapering may take time.
The Therapeutics Initiative at the University of British Columbia (UBC) is hosting a series of webinars with healthcare professionals sharing real-life stories about their own patients whose medications they were able to reduce, and what happened when they did. To bring deprescribing to life, healthcare professionals are sharing the stories of their patients, with the patients’ permission.
The following story is the fifth in our deprescribing series.
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Prioritizing the First Deprescribing Steps
The woman has “an extensive mental health history,” says Quintal.
“She’s got a diagnosis of borderline personality disorder,” says Quintal. “She has chronic depression, codeine use disorder, fetal alcohol spectrum disorder, and post-traumatic stress disorder (PTSD).”
In addition, the patient has asthma, sleep apnea, a history of thrombosis (blood clots), and high blood pressure that can affect the brain. The woman was taking 14 different drugs. First, the woman’s primary care doctor tapered her off gabapentin (which can be prescribed for a variety of reasons including pain and anxiety), then referred her to Quintal to help with other medications.
Before suggesting that she stop or taper any particular drug, Quintal asked the woman how she felt about the medications she was taking. Which did she feel like really helped her? Which didn’t seem to make a difference or caused side effects?
“She was very clear that prazosin was really helpful with her nightmares from PTSD,” says Quintal. “She thought olanzepine was really helpful for her. It helped to steady her thoughts and just keep her mood stable. She thought that the oxybutynin was helpful for urinary frequency, and she really was happy with baclofen for neck pain.”
Quintal explains that the patient wasn’t convinced that divalproex, a bipolar drug, was helping her, because she hasn’t been diagnosed with bipolar disorder. She knew that amitriptyline, a drug for sleep, could cause weight gain and said her sleep had been fine recently. Lastly, she wasn’t sure why she’d been prescribed acetazolamide and wanted to stop that drug.
She didn’t feel strongly about starting or stopping the several other drugs she was taking, including: escitalopram for depression, rabeprazole which is a proton pump inhibitor (PPI) that treats acid reflux, rivaroxaban to prevent blood clots, clonidine for blood pressure, a salbutamol inhaler for asthma attacks and buprenorphine/naloxone for her codeine use disorder.
Making a Deprescribing Plan
First, Quintal determined that the woman had been prescribed acetazolamide to manage her intracranial hypertension. Once she explained this to the patient, the two decided it would be best to continue taking the medication. Olanzepine, the medication the woman felt had helped her stabilize her mood, was the most likely to be causing weight gain, but the two decided that the benefit was worth it. That left amitriptyline (an antidepressant) and divalproex (which can treat mood disorders and migraines) as the drugs to consider decreasing first.
“We decided at this appointment to start with amitriptyline as the low-hanging fruit. It’s very easy to taper off of and you can split the pills,” said Quintal. They postponed discussing divalproex to a later appointment.
Four Months into Deprescribing
When the woman came in for her four-month follow up, she was happy with her progress so far, and curious about reducing some other drugs. First, she’d been taking baclofen four times a day and wondered if she could simplify that regimen, explained Quinta. Next, she was still concerned about her weight, so she wanted to know if there were alternatives to the olanzapine and divalproex that she takes to help stabilize her mood, though she was worried since they’d seemed to work well so far. Both drugs are associated with weight gain, but olanzapine is more strongly associated with metabolic issues. They weighed the pros and cons of stopping each medication.
“We decided to start with just a reduction in the divalproex,” said Quintal, “and to come back to olanzapine, and reconsider something to substitute for it at another visit.” Since she was still concerned about weight, the two discussed drugs that might help with her weight. Insurance wouldn’t cover semaglutide, so she agreed to try metformin, a diabetes drug that might help with weight loss.
Seven Months into Deprescribing
The woman hadn’t yet started on metformin by her seven-month follow-up. She hadn’t been able to make it to an appointment with her primary care provider who would write a prescription for it yet. She’d cut down her baclofen from four doses a day to three and her neck pain was fine. She’d lowered the dose of her divalproex from 2,000 milligrams per day to 1,500 milligrams.
The woman expressed that instead of continuing to reduce the divalproex dose, she’d much rather discuss alternatives to the olanzapine. In the past, she’d been prescribed aripiprazole (Abilify), which has fewer metabolic side effects than olanzapine, but she switched drugs because it hadn’t worked very well. Reflecting on the experience, she wondered if the reason she didn’t respond to the drug was that life was much less stable at the time, and now that she felt more stable, so it might be more effective.
Quintal and the patient decided to gradually taper off of the olanzapine while simultaneously tapering up to an effective dose of aripiprazole. Aripiprazole has well-known movement-related side effects so the two had to review that risk and discuss what to look for.
After this visit, she also started metformin.
Ten Months into Deprescribing
At this appointment, she’d completely tapered off of the olanzapine and had reached an effective dose of aripiprazole.
“She was quite happy with that switch,” said Quintal, although she found that the drug was making her sleepy, and asked if she could take it in the evening rather than the morning. Although Quintal decided not to weigh the woman, the woman said she liked the metformin and wanted to consider increasing that dose.
Unfortunately, she started to notice some side effects she hadn’t felt before. The clonidine, she said, was making her sleepy. The oxybutynin was making her feel a little paranoid and she was having difficulty speaking after doses. She didn’t feel like the drug for her PTSD nightmares was as effective as she’d hoped.
Still, Quintal said it’s crucial to go slowly and not try too many changes at once. So, after discussing her options, the two decided the woman would take her aripiprazole before bed, she’d try a higher dose of metformin, and she’d cut the dose of oxybutynin in half. They’d talk about the clonidine at her next appointment.
Quinta is still working with the woman. So far, she’s stopped taking four medications: olanzapine, amitriptyline, gabapentin and the salbutamol inhaler. She’s reduced her doses of another three: divalproex, baclofen and oxybutynin, and she started three new drugs: aripiprazole as an alternative to olanzapine, metformin, and a new inhaler, Symbicort.
“We’ve managed to stop four medications, three of which were highly anticholinergic,” said Quintal. Anticholinergic drugs are drugs that block a neurotransmitter called acetylcholine. Acetylcholine is involved in many processes and diseases, so blocking it can have wide ranging effects from drying out your nasal passages to treat allergies (antihistamines are anticholinergic) to preventing involuntary movement in Parkinson’s. And the side effects—such as dry mouth, bowel obstruction, blurred vision, and memory impairment—of anticholinergic drugs can be cumulative.
Most importantly, she says that by prioritizing her patient’s concerns, Quinta has built a strong and trusting relationship that will allow them to keep safely lowering the side effects of her medications over time.
Check out the other articles in this series:
Cutting Down on Medications for Time with the Great Grandkids
Deprescribing to Be a Better Dad
A Little Less Medicine, A Little More Camping
Symptoms or Side Effects? Deprescribing a young Woman
To learn more about deprescribing, check out our articles here:
How to Take Fewer Medications
Too Many Prescriptions? How to Talk to Your Doctor About It
Can I Cut Down the Number of Drugs I Take?
