• Gabapentinoids were the most common medications chosen for a deprescribing attempt.
• No serious adverse events were reported for patients who attempted to deprescribe medications.

A protocol for deprescribing inappropriate medications for patients on hemodialysis was feasible and well received, according to study data.

However, nephrologists who participated in the study said the deprescribing process may be difficult to integrate into their clinical workflow.

Inappropriate medications, such as gabapentinoids and muscle relaxants, are commonly prescribed to older adults on hemodialysis but can lead to adverse events, such as falls, extreme drowsiness, confusion, hospitalization and mortality, Rasheeda Hall, MD, MBA, MHS, associate professor of medicine and population health sciences at Duke University School of Medicine, and colleagues wrote in Kidney360.

Deprescribing may help to prevent adverse events associated with inappropriate medications. The researchers designed the IMPROVED study, a nonrandomized feasibility study, to evaluate the demand, efficacy, acceptability and practicality of deprescribing inappropriate medications for adults aged 55 years and older on hemodialysis.

“In this study, we focused on potentially inappropriate medications — a term from geriatrics literature referring to medications that carry a greater risk of harm than benefit for older adults,” Hall told Healio. “The risk of harm arises because older adults generally can be more vulnerable to side effects of medications. If they have kidney disease too, then the risk of harm could be heightened, especially if the medication involves the kidneys for clearance.”

The deprescribing process involved three steps: medication review (via hospital electronic medical records), delivery of the deprescribing recommendation (via a rounding sheet with multiple patient recommendations per sheet) and study team-led decision-making (with the help of a research nurse). Deprescribing conversations focused on tapering instructions, alternative treatment options and monitoring for adverse withdrawal events.

After reviewing more than 600 patient charts and engaging in shared decision-making, 41 patients (mean age, 67 years; 54% men; 78% Black) were deemed eligible for a deprescribing attempt and approached by either a physician or study team member. Ultimately, 17 patients agreed to a deprescribing attempt, with most attempts focused on deprescribing gabapentinoids.

“Gabapentin is commonly prescribed in this population for pain management, and neuropathic pain is common in the dialysis population,” Hall said. “There is data to suggest that these prescriptions have increased in recent years as there has been a push to reduce opioids.”

Results showed that after a deprescribing attempt, 41% of patients experienced symptom recurrence, including six patients who discontinued a gabapentinoid and one patient who discontinued a muscle relaxant. Most patients who discontinued a gabapentinoid remained off it at 3 months, but the patient who discontinued a muscle relaxant resumed it at 3 months.

Despite the recurrence, no patients experienced a severe adverse event requiring an ED visit, hospitalization or death, according to the researchers.

From available patient responses (n = 10), patients reported that the discussions on deprescribing were positive, but some wanted more concise explanations for why it was recommended.

“Some patients may think that removing a medication is a way for a clinician to deny them something or take away something that works, not recognizing it was intended to help them avoid an adverse event,” Hall said. “This makes sense if the clinician is not clear in their explanation or the patient has medical mistrust.”

From seven available nephrologist responses, five reported deprescribing was doable in practice and two said the deprescribing protocol fit well within their clinical workflow. These responses suggest implementing the deprescribing protocol into existing clinical routines was the largest barrier to its use, the researchers wrote.

Overall, the findings suggest deprescribing was feasible, well received by patients and did not result in severe adverse drug withdrawal events, according to the researchers.

Further research is needed to better integrate deprescribing conversations into clinical workflows and improve shared decision-making, Hall said. A clinical trial on deprescribing is also needed, she said.

“It can be hard to champion a change in routine if it doesn’t show a benefit,” Hall said. “An ideal study would be a clinical trial that demonstrates positive outcomes in patients who do undergo deprescribing. However, more work needs to be done before such a trial could be executed, including engaging pharmacists and other clinicians in the deprescribing process and identifying viable alternatives to address the symptoms that these patients encounter. Only then could we have a chance at enrolling participants.”

Rasheeda Hall, MD, MBA, MHS, can be reached at rasheeda.hall@duke.edu.