Novant Health Presbyterian Medical Center, Department of Pharmacy, Charlotte, NC.
Grady Health System, Department of Pharmacy and Drug Information, Atlanta, GA.
J Am Med Dir Assoc. 2018 Nov;19(11):923-935.e2. doi: 10.1016/j.jamda.2018.06.021. Epub 2018 Aug 11.
Perform a systematic review to evaluate the outcome of deprescription compared with standard care. The focus was on chronic medical and mental health conditions managed in primary care.
The databases searched include PubMed, Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science. Each study was assessed for bias with the Cochrane Collaboration tool.
This review included outpatient, assisted living, nursing home, and acute care settings (if medications for chronic disease were deprescribed). Subjects were non-terminally ill adults 18 years and older.
Primary outcome was successful deprescription, defined as a statistically significant reduction in medication burden between the intervention group and the standard care or control group, or when more than 50% of intervention subjects were able to tolerate medication discontinuation compared with control by the end of the study.
Fifty-eight articles met the study criteria. Thirty-three (58%) had a high risk of bias. Studies varied in duration from 4 weeks to 5 years and were conducted across a diverse array of primary health care settings. The most successful interventions used pharmacist-led educational interventions and patient-specific drug recommendations. Cardiovascular drugs including antihypertensives/diuretics and nitrates were the most successfully deprescribed class of drugs. Psychotropic medications and proton-pump inhibitors were the classes most resistant to deprescribing, despite intense intervention.
CONCLUSIONS/IMPLICATIONS: Deprescription may be successful and effective in select classes of drugs, with collaboration of clinical pharmacists for patient and provider education, and patient-specific drug recommendations, complemented by close clinical follow-up to detect early signs of exacerbation of chronic diseases. This review also suggests that deprescription may (1) require expensive intensive, ongoing interventions by clinical teams; (2) not lead to expected outcomes such as improved falls rate, cognition, and quality of life, or a lower admission rate; and (3) have unexpected adverse outcomes affecting patients' quality of life.
系统评价比较减药与标准护理治疗的结果。重点是管理初级保健中慢性医学和精神健康状况。
检索的数据库包括 PubMed、Medline、EMBASE、Cochrane 图书馆、Scopus 和 Web of Science。使用 Cochrane 协作工具评估每项研究的偏倚。
本综述包括门诊、辅助生活、护理院和急性护理环境（如果为慢性疾病减药）。研究对象为 18 岁及以上非终末期成年人。
主要结果是成功减药，定义为干预组与标准护理或对照组相比药物负担有统计学显著减少，或研究结束时干预组中超过 50%的患者能够耐受停药，与对照组相比。
58 篇文章符合研究标准。33 篇（58%）存在高偏倚风险。研究持续时间从 4 周到 5 年不等，在各种初级保健环境中进行。最成功的干预措施使用药剂师主导的教育干预和针对患者的药物建议。心血管药物包括降压药/利尿剂和硝酸盐是最成功减药的药物类别。尽管进行了强化干预，但精神药物和质子泵抑制剂是最难减药的类别。
结论/意义：在临床药师为患者和医务人员提供教育和针对患者的药物建议，以及密切的临床随访以发现慢性疾病恶化的早期迹象的情况下，减药可能是成功和有效的，可选择特定类别的药物。本综述还表明，减药可能（1）需要临床团队进行昂贵的密集、持续干预；（2）不会带来预期的结果，如改善跌倒率、认知和生活质量，或降低入院率；（3）产生影响患者生活质量的意外不良后果。
