Prescription flip-side: Guidelines for medication withdrawal

in the elderly, but as the authors combed through them with their frail older patients in mind they noticed that none considered when medications that might have previously been appropriate should be discontinued.

"Most drug studies tell you how to treat the chart, how to treat the numbers," said co-author Caleb Alexander, M.D., assistant professor of medicine and a member of the Center for Clinical Medical Ethics at the University of Chicago, "but they don't always help you treat the patient. We set out to fill some of those gaps."

One of those gaps was prognosis. Drugs with long-term benefits, such as those for high blood pressure or elevated cholesterol, provide no immediate relief, are seldom entirely without side effects and can be quite expensive, especially for the elderly who often take many different drugs. Such medications may be appropriate for a 65-year old with mild heart disease but at some point in the next 25 years patient and physician may have to overcome what the authors refer to as "clinical inertia" and rethink that initial decision.

The authors suggest four criteria for doctors considering adding -- or subtracting -- a drug from an elderly patient's therapeutic arsenal. First is to calculate the patient's life expectancy, based on actuarial charts and modified by the patient's current health status and history. Second is to weigh the time to benefit. Pain relief may be immediate but some preventive medications, such as a statin, may not provide any benefit for years. Third is to work with the patient and family to determine the goals of care, a shifting balance of prevention, treatment and palliation. Fourth is to define treatment targets, such as relief of specific symptoms, that agree with the goals of care.

Even when it makes clinical sense to take patients off of a medicine, the authors note, it can be emotionally challenging. Sixty-five percent of all office visits end with the granting of a prescr

Contact: John Easton or Catherine Gianaro
University of Chicago Medical Center

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