Every year, I like to reflect on the common recommendations I make pertaining to drug therapies. These recommendations often reflect the practice of the time, new exciting therapies that have just emerged as well as new warnings released by regulatory authorities such as Health Canada or FDA. It also helps me to identify learning gaps for nurses and physicians so that I can plan relevant education or in-services accordingly.
So for 2016, below are my top 10 recommendations that I make, mostly for the geriatric population in long term care facilities:
- Stop the calcium supplement – here’s a summary of why we don’t recommend calcium supplement routinely anymore. In short, it is best to obtain calcium from dietary sources if possible.
- Stop docusate sodium (Colace) – it’s no news that docusate sodium does’t work well. But sometimes it’s hard to break the habit. Really, it doesn’t work well for the chronic constipation. Here’s my rant about the topic. For some reason, it is my most popular post this year and continues to have consistent traffic from various search engines. Either I have hit the right key words, or many people are indeed wondering about the effectiveness of this little red gelcap.
- Taper inhaled corticosteroid or optimize COPD therapy with new improved inhalation devices – I have also started encouraging a closer look at the inhalation therapies for the existing COPD patients. Often times, they have been put on the inhalation therapies for years without questioning their effectiveness or safety. We have new evidence and new devices – I often took the opportunity this year to see if there is room for optimization.
- Start sodium glucose cotransporter inhibitor in Type II diabetes – the management of diabetes continues to change with time. This year, I must say I am a big fan of sodium glucose cotransporter inhibitor. Not everyone can or should begin this therapy but it is one medication that may change the way we manage Type II diabetes as more positive evidence continues to emerge. Here’s my post about this drug.
- De-prescribing Proton Pump Inhibitor – Deprescribing is also a popular theme for 2016 in drug management. Polypharmacy continues to be related to increased risk of adverse drug events and is associated with poor outcome. Many physicians are warming up to the idea and I have started some deprescribing initiatives with proton pump inhibitor being the first class to be targeted.
- Reassess benzodiazepine – this isn’t a new venture for me. There is plenty of evidence to suggest its harm, its habit forming potential and its possible link to the increased risk of fall and cognition worsening. But there is strong resistance usually from the patients and less incentive for clinicians to address them with courage. I often entertain the idea of removing these toxic substance from our formulary and limiting public access. If we know it’s bad for many reasons, why does it take so long to do something effective about it?
- Stop the iron if no longer anemic – This is an ongoing recommendation I tend to make with my patient population. Often times, we are quick to start iron supplement especially when we see the patient is anemic with iron deficiency. But once this is corrected several months later, we don’t always remember to stop the supplement. Please take note – iron supplements are very nauseous and constipating, so stop it if no longer needed. The only exception is perhaps when they have end stage chronic kidney diseases and/ or is prone to anemia (e.g. possible GI bleed that is not investigated).
- Stop Milk of Magnesia in renal impairment – Many people don’t realize magnesium can accumulate in renal impairment. So it is best to avoid Milk of Magnesia especially if we have other equivalent treatment options to select for constipation and or heartburn.
- Reassess antipsychotics – Recently, many long term care facilities have placed more emphasis on reducing antipsychotic usage given the concerned safety of its prolonged use in the dementia population (e.g. increased risk of stroke & death). The media has portrayed it negatively but I feel we are moving in the right direction, at least based on the most recent statistics. There is still more work to be done and hopefully we continue to have to same dedication in 2017.
- Initiate antihypertensive or screening for metabolic syndrome (prediabetes) – Recently, the Ontario Drug Benefits Program has made some changes to our Medscheck program for Long Term Care Facilities. Particularly, it is only eligible to individuals on at least three prescription medications. I find this a bit unfair because I routinely see many individuals not on any prescription medication yet they are indeed needed to start either anti-hypertensives or oral hypoglycemic agents. The potential cardiovascular benefits from initiating these therapies can be significant, yet the work that goes into these recommendations are not recognized, nor reimbursed.
So here are my top 10 recommendations for 2016. I look forward to a great start in 2017.