Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.
Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, USA.
United European Gastroenterol J. 2021 Mar;9(2):193-202. doi: 10.1177/2050640620975224. Epub 2021 Feb 18.
Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis.
We conducted, transcribed, and analyzed semi-structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing.
Major provider-specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient-specific barriers included knowledge gaps regarding the cirrhosis-specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach.
Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy-based deprescribing outreach and patient-facing education on risks are warranted.
多种药物与肝性脑病的发生风险增加相关。尽管存在这种已知风险，但仍有越来越多的人将阿片类药物、苯二氮䓬类药物、加巴喷丁/普瑞巴林和/或质子泵抑制剂等药物开给肝硬化患者。撤药是减少肝性脑病负担的一种有前途的干预措施。鉴于撤药尚未在肝硬化中进行试验，我们评估了肝硬化中安全且成功撤药的障碍和促进因素。
我们使用定性方法进行了半结构式访谈，并对 22 名受试者进行了转录和分析。这包括 8 名患有肝硬化且最近使用阿片类药物、苯二氮䓬类药物、加巴喷丁/普瑞巴林和/或质子泵抑制剂的患者，以及 14 名提供者（初级保健、移植手术、移植肝脏病学）。访谈探讨了与撤药风险和益处相关的意见、行为和理解。
主要提供者特定的障碍包括撤药过程的责任推迟、对与药物（例如质子泵抑制剂）相关的肝性脑病风险以及安全撤药方法（即苯二氮䓬类药物）的知识空白，以及时间限制。患者特定的障碍包括对其药物与肝硬化相关风险的知识空白以及对停药后症状复发的焦虑。患者普遍报告信任他们的提供者对风险的意见，并希望在就诊期间或之后获得更全面的教育。提供者普遍报告支持包括药剂师或护士外展的撤药资源。
鉴于肝硬化患者对与肝性脑病相关的药物风险的了解，撤药被普遍认为很重要。对可行替代方案的知识空白、不作为和不确定性阻碍了有意义的撤药实施。需要进行基于方案的药物治疗师外展和针对风险的患者教育的试验。
