Hemodialysis (HD) patients are all too familiar with taking many medications simultaneously – averaging 12 or more per day. However, many of these medications may not be necessary.
To relieve this heavy pill burden, a group of researchers from British Columbia, Alberta, Manitoba and Ontario, including patient partners, teamed up to develop a new clinical tool that safely and effectively identifies which medications can be deprescribed for a given population of HD patients. The new tool is described in a study published last October in the Canadian Journal of Kidney Health and Disease.
At the heart of their approach are medication-specific algorithms for nine different classes of drugs that are commonly taken by HD patients.
“The algorithms provide a step-by-step plan for each specific medication, outlining how and when to deprescribe,” explains Marisa Battistella, principal investigator of the research project and a pharmacy clinician scientist with the Leslie Dan Faculty of Pharmacy, University of Toronto. “With each step there are recommendations on symptoms and/or labs to monitor at specific time points.” To develop the algorithms, Battistella’s team first analyzed medication use with HD patients via databases from Ontario, Manitoba and British Columbia.
Judith Marin is a clinical pharmacotherapeutic specialist with the Providence Health Care Renal Program, based at St. Paul's Hospital, who helped lead the BC component of the study.
"Even though I'm aware that dialysis patients take a considerable number of medications, I was surprised that BC dialysis patients take an average number of 18 medications, including an average of five potentially inappropriate medications," says Marin. "This confirmed to us that this initiative has some merits."
The research team also conducted a national survey of nephrologists to identify the nine medication classes that could be assessed and deprescribed for these patients. For each medication algorithm, an accompanying safety and efficacy monitoring tool was included.
Then, an extensive, three-round validation process was done, whereby 70 clinicians from across Canada – including nurses, nurse practitioners, dietitians, renal pharmacists and nephrologists – worked to refine and revise the clinician’s toolkit (algorithm, evidence table, and monitoring form). Battistella says this process has helped increase the toolkit’s generalizability to a diverse Canadian HD population, and will hopefully promote greater acceptance by clinicians.
Notably, many patients may feel uncomfortable with the deprescribing process if one doctor prescribes a medication and then another says it’s okay to reduce or eliminate the medication. Therefore, a set of educational materials, in the form of bulletins and videos, was created in lay terms and validated to support HD patients in the deprescribing process.
Battistella notes that similar deprescribing interventions have been successful in other populations of patients, and have been associated with lower medication costs, fewer long-term care referrals, decreased mortality and improved perceptions of overall personal health.
Both Battistella and Marin emphasize that a particularly rewarding aspect of this project has been working closely with patient partners.
“It is heartwarming and inspiring to see how dedicated they are to our project and moving this project forward,” says Battistella.
Next, the team plans on launching a clinical trial to evaluate the deprescribing toolkit in four hemodialysis units across Canada. The trial is tentatively set to launch this fall.