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. 2022 May 13:9:20543581221098778.
doi: 10.1177/20543581221098778. eCollection 2022.

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

Joseph Moryousef  1 , Émilie Bortolussi-Courval  2 , Tiina Podymow  3 , Todd C Lee  4   5 , Emilie Trinh  3 , Emily G McDonald  2   4   6   7
Affiliations

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

Joseph Moryousef et al. Can J Kidney Health Dis. .

Abstract
in English, French

Background: End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs).

Objective: To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms.

Design: Secondary analysis of a cluster randomized clinical trial.

Setting: Medical units in 11 acute care hospitals in Canada.

Patients: The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis.

Measurements: The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing.

Methods: Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing.

Results: There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents.

Limitations: This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions.

Conclusion: MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.

Contexte: Le risque de polypharmacie est important chez les patients atteints d’insuffisance rénale terminale (IRT) sous dialyse en raison de leurs nombreuses comorbidités et de leurs contacts fréquents avec le système de santé. MedSafer est un outil électronique d’aide à la décision qui intègre les comorbidités et la liste de médicaments des patients pour générer des rapports de déprescription personnalisés, axés sur l’identification de médicaments potentiellement inappropriés (MPI).

Objectifs: Procéder à une analyse secondaire des patients sous hémodialyse inclus dans l’essai contrôlé randomisé MedSafer dans le but d’examiner les profils de polypharmacie et d’évaluer l’efficacité des algorithmes de déprescription de MedSafer.

Type d’étude: Analyse secondaire d’un essai clinique randomisé en grappes.

Cadre: Les unités médicales de onze hôpitaux de soins aigus au Canada.

Sujets: L’essai MedSafer a inclus 5698 patients de 65 ans et plus avec un pronostic attendu de plus de trois mois et prenant au moins cinq médicaments quotidiennement à domicile; 140 patients étaient traités par hémodialyse chronique.

Mesures: Le principal critère d’évaluation de l’essai était la survenue d’événements indésirables attribuables aux médicaments (ÉIM) dans les 30 jours suivant le congé de l’hôpital. Un des principaux critères d’évaluation secondaires était la déprescription.

Méthodologie: Les patients du groupe témoin recevaient les soins habituels (bilan comparatif des médicaments) alors qu’un rapport MedSafer soulignant les possibilités de déprescription individuelles était envoyé aux cliniciens qui prenaient en charge les patients du groupe d’intervention.

Résultats: Chaque bras de l’essai (témoin et intervention) comptait 70 sujets. Le nombre médian de médicaments pris à domicile était de 14 (comparativement à 10 dans la population générale de l’essai). Les médicaments les plus souvent cités comme potentiellement inappropriés étaient les inhibiteurs de la pompe à protons (55/76 patients; 72,4%), les médicaments contre le diabète chez les patients avec un taux d’HbA1c inférieur à 7,5% (36/65 patients; 55,4%), le docusate (27/27 patients; 100%), les gabapentinoïdes (27/36 patients; 75%) et les antiplaquettaires/anticoagulants combinés (22/97 patients; 22,7%). La proportion de MPI déprescrits était plus élevée dans la phase d’intervention que dans la phase témoin (28,8% c. 19,3%; augmentation absolue de 9,4% [IC 95%: 1,3 à 17,6%]). Aucune différence n’a été observée entre les deux groupes en ce qui concerne les ÉIM dans les 30 jours suivant le congé de l’hôpital. Une hémorragie gastro-intestinale attribuable aux agents antiplaquettaires était l’événement indésirable le plus fréquent (n = 3).

Limites: Il s’agit d’une analyse exploratoire a posteriori. L’essai initial n’a pas été stratifié selon le status en hémodialyse. La faible taille de l’échantillon ne permet pas de tirer des conclusions définitives.

Conclusion: MedSafer facilite la déprescription chez les patients hospitalisés qui reçoivent des traitements d’hémodialyse. Pour démontrer un éventuel impact sur les événements indésirables attribuables aux médicaments, il apparaît nécessaire de faire un suivi à plus long terme et à plus grande échelle du logiciel d’aide à la décision de déprescription en contexte de dialyse.

Keywords: chronic kidney disease; deprescribing; hemodialysis; polypharmacy.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs McDonald and Lee are the cocreators of MedSafer and own MedSafer CORP. The intellectual property is shared with McGill University. MedSafer was funded by grants from the Canadian Institutes for Health Research, the Canadian Frailty Network, and the Centre for Ageing and Brain Health Innovation. Drs McDonald and Lee receive salary support for research from the Fond de recherche santé Québec. The other authors have no disclosures to declare.

Figures

Figure 1.
Figure 1.
Frequency of drugs consumed in cohort (n = 140) and the proportion of flagged PIMs. Note. PIM = potentially inappropriate medication; PPIs = proton pump inhibitors; ACE-I/ARB = angiotensin converting enzyme inhibitors/angiotensin receptor blockers; SSRIs = selective serotonin reuptake inhibitors.
Figure 2.
Figure 2.
Most common PIMs/PIM classes and the deprescription proportions in the control versus intervention groups. Note. PIMs = potentially inappropriate medications; PPIs = proton pump inhibitors.
Figure 3.
Figure 3.
Total count of high-, intermediate-, and low-risk PIMs identified and deprescribed in the (A) whole cohort, (B) control, and (C) intervention group. Note. PIMs = potentially inappropriate medications.
See this image and copyright information in PMC

References

    1. Thurlow JS, Joshi M, Yan G, et al. Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy. Am J Nephrol. 2021;52(2):98-107. doi: 10.1159/000514550. - DOI - PMC - PubMed
    1. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80:1258-1270. doi: 10.1038/ki.2011.368. - DOI - PubMed
    1. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230. doi: 10.1186/s12877-017-0621-2. - DOI - PMC - PubMed
    1. Romagnani P, Remuzzi G, Glassock R, et al. Chronic kidney disease. Nat Rev Dis Primers. 2017;3:17088. doi: 10.1038/nrdp.2017.88. - DOI - PubMed
    1. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382:260-272. doi: 10.1016/s0140-6736(13)60687-x. - DOI - PubMed

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