1Pharmacy Outcomes Research Group.
3Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland.
J Manag Care Spec Pharm. 2019 Aug;25(8):927-934. doi: 10.18553/jmcp.2019.25.8.927.
In the elderly, use of medications may increase the propensity for adverse drug events due to alterations in pharmacokinetic and pharmacodynamic profiles from normal aging processes. Deprescribing is the planned and supervised process of dose reduction or discontinuation of medications that may lead to harm or are no longer beneficial. While there are studies detailing strategies to deprescribe medications such as benzodiazepines and antipsychotics in nursing homes or for patients with dementia, there is a lack of guidance to safely deprescribe chronic medications, such as antidiabetics, for older patients in the community setting.
To evaluate the risk of hypoglycemia and other outcomes of pharmacist-managed deprescribing on selected antidiabetic medications under the guidance of a standardized program compared with usual care within an integrated health care system.
This was a retrospective propensity score-matched cohort study. The pharmacist-managed deprescribing group included patients who were enrolled in the deprescribing program between July 1, 2016, and June 30, 2017. The usual care group included eligible patients who did not receive the deprescribing intervention and were matched to the deprescribing group using propensity score matching (PSM). Baseline demographics and clinical variables were used for matching. Patients were followed for 6 months or the end of membership or death, whichever occurred first. Primary outcome was the risk of hypoglycemia. Secondary outcomes included risk of hyperglycemia, proportion of patients at goal (A1c), change in A1c, change in monthly antidiabetic drug cost, and all-cause mortality. Outcomes were analyzed using descriptive statistics and multivariant regression or Cox proportional hazard models when appropriate.
After PSM, 685 patients in the deprescribing group and 2,055 patients in the usual care group were similar in age, gender, weight, and comorbidity burden (mean [SD] age 82.4 [5.4] years, 48% female, mean [SD] weight 81.7 [19.2] kg, mean [SD] Charlson Comorbidity Index score 3.2 [1.6]). Compared with the usual care group, the deprescribing group had a lower risk of hypoglycemia (1.5% vs. 3.1%, < 0.02; adjusted odds ratio 0.42, < 0.01). As for the secondary outcomes, the deprescribing group had a greater change (SD) in A1c (0.3 [0.6] vs. 0.2 [0.7] < 0.01) and lower all-cause mortality (2.3% vs 5.6%, < 0.01; adjusted hazard ratio 0.35, < 0.01). There were no differences observed in the risk of hyperglycemia, proportion of patients at goal A1c < 7%, and change in monthly antidiabetic drug costs between the 2 groups.
There are currently no studies to our knowledge that evaluate the outcomes of a pharmacist-managed deprescribing program targeting antidiabetic medications. The results of our study showed that deprescribing of selected antidiabetics reduced the risk of hypoglycemia and may have mortality benefit in elderly patients with well-controlled type 2 diabetes, who are taking medications that can cause hypoglycemia. Further and longer studies are needed to validate these benefits.
No outside funding was provided to support this research study. The authors of this study have no actual or potential conflicts of interest to report. Parts of this study were presented in a nonreviewed resident poster at the Academy of Managed Care Pharmacy Managed Care and Specialty Pharmacy Annual Meeting; April 23-26, 2018; Boston, MA.
在老年人中，由于正常衰老过程中药物代谢动力学和药效学特征的改变，药物的使用可能会增加发生不良药物事件的倾向。减少药物剂量或停止使用可能会导致伤害或不再有益的药物是有计划和监督的过程，称为药物精简。虽然有研究详细介绍了在养老院或痴呆患者中减少苯二氮䓬类药物和抗精神病药物等药物的策略，但缺乏在社区环境中为老年患者安全减少慢性病药物（如糖尿病药物）的指导。
评估在综合医疗保健系统中，在标准化计划的指导下，由药剂师管理的药物精简方案与常规护理相比，对选定的糖尿病药物的低血糖风险和其他结果的影响。
这是一项回顾性倾向评分匹配队列研究。药剂师管理的药物精简组包括 2016 年 7 月 1 日至 2017 年 6 月 30 日期间参加药物精简计划的患者。常规护理组包括符合条件但未接受药物精简干预的患者，并使用倾向评分匹配（PSM）与药物精简组进行匹配。使用基线人口统计学和临床变量进行匹配。患者在 6 个月或会员资格结束或死亡时（以先发生者为准）进行随访。主要结局是低血糖风险。次要结局包括高血糖风险、达到目标 A1c 的患者比例（A1c）、A1c 变化、每月糖尿病药物费用变化和全因死亡率。使用描述性统计和多变量回归或 Cox 比例风险模型分析结局，必要时进行分析。
在 PSM 后，药物精简组的 685 名患者和常规护理组的 2055 名患者在年龄、性别、体重和合并症负担方面相似（平均[SD]年龄 82.4[5.4]岁，48%女性，平均[SD]体重 81.7[19.2]kg，平均[SD]Charlson 合并症指数评分 3.2[1.6]）。与常规护理组相比，药物精简组低血糖风险较低（1.5%比 3.1%，<0.02；调整后的优势比 0.42，<0.01）。至于次要结局，药物精简组的 A1c 变化（0.3[0.6]比 0.2[0.7]，<0.01）更大，全因死亡率较低（2.3%比 5.6%，<0.01；调整后的风险比 0.35，<0.01）。两组间高血糖风险、达到目标 A1c<7%的患者比例和每月糖尿病药物费用变化无差异。
据我们所知，目前没有研究评估针对糖尿病药物的药剂师管理药物精简方案的结局。我们的研究结果表明，减少选定的糖尿病药物可以降低低血糖风险，并可能在血糖控制良好的 2 型糖尿病老年患者中具有降低死亡率的益处，这些患者正在服用可能导致低血糖的药物。需要进一步和更长时间的研究来验证这些益处。
本研究没有外部资金支持。本研究的作者没有实际或潜在的利益冲突需要报告。本研究的部分内容以未经评审的居民海报形式在管理式医疗药房管理式护理和专科药房年会（2018 年 4 月 23 日至 26 日，马萨诸塞州波士顿）上进行了介绍。
