Prescription medications are needed for many people facing chronic kidney disease, but not all of them need to be taken long-term. Taking too many medications can, in some cases, cause more harm than good. Still, patients can be reluctant or afraid to stop a medication, even if it’s no longer necessary, especially if they think it helps them.  

This raises questions as to how patients and their doctors, pharmacists, and other care providers can work together to reduce the number of unnecessary medications prescribed — a process known as “deprescribing”. 

An implementation study, led by clinician-scientist and pharmacist Dr. Marisa Battistella at the University Health Network in Toronto, aims to support patients on hemodialysis in optimizing medication use. Its initial success provides valuable insights into implementing patient-centred deprescribing practices that focus on engaging patients in their care through education and communication with care providers. 

Deprescribing in action 

As part of a Can-SOLVE CKD research project called STOPMed-HD, Battistella and her colleagues spent years developing a novel deprescribing toolkit that can be used by patients and their doctors to review medications commonly prescribed to people on hemodialysis and identify which ones they may no longer need to take. The medications include alpha-1 blockers, benzodiazepines and Z-drugs, gabapentinoids, loop diuretics, prokinetic agents, proton pump inhibitors, quinines, statins, and urate-lowering agents.  

“If a medication [isn’t] doing anything, why take an extra pill that might be causing side effects?” Battistella says, noting that gabapentin, for example, can cause dizziness, tiredness, and weakness. “If that medication isn’t really helping a patient and we deprescribe it, I think this improves their quality of life and helps people feel better.”  

The deprescribing toolkit developed by the STOPMed-HD team, which includes several patient partners, consists of deprescribing algorithms for care providers and patient-centred information bulletins and videos. The toolkit has proven to be effective, but the researchers needed a way to bring it into hemodialysis clinics across the country.  

They began by implementing a deprescribing program using the toolkit at a hemodialysis site in Toronto, followed by one in Halifax, and exploring what factors supported or hindered uptake of deprescribing through interviews with patients and care providers.  

At the Toronto site, care providers worked together to apply the deprescribing toolkit and identified medications that could potentially be stopped in 40 patients. Of those patients, 25 decided to stop using the unnecessary medications identified. No adverse effects resulted from stopping the medications, and 20 out of 25 patients continued to stay off the medications at the end of the six-month pilot study.  

Helping patients make informed decisions 

In interviews with the study participants, the research team learned that many patients see reducing their pill burden as a benefit — which is not surprising, since hemodialysis patients take an average of 12 pills a day.  

To support patients in making the decision to deprescribe, the researchers provided them with information on the rationale, risks, and benefits to deprescribing in the form of pamphlets and video interviews with other patients. 

In one video, a hemodialysis patient named Reuben shares his story, explaining how he was prescribed a medication for gout 10 years ago and continued to take it even though he no longer needed it. The STOPMed-HD deprescribing toolkit helped him and his health care team determine that he was able to safely stop taking that medication, as well as another one that was a duplicate medication. “When you are taking 13, 14 medications a day, removing one is tremendous,” says Reuben. 

Along with hearing firsthand accounts from patients like Reuben, participants in the study said that having a trusting relationship with their care team made them more likely to want to try to deprescribe. As well, they appreciated if their care team provided regular check-ins and followed up with them after stopping a medication, ensuring proper monitoring in case there were any issues. 

Among the patients who declined to deprescribe, some expressed fear of removing a medication, or a fear that they would not be monitored closely by their doctors if issues came up. 

In interviews with care providers, some noted that time limitations are a barrier for them when it comes to using the deprescribing toolkit. But in general, Battistella says, the care providers involved in this pilot study saw the toolkit’s value and were very open to using it.  

A lighter pill burden for all 

While the team has completed its interviews with study participants in Toronto and Halifax, the research is still underway at sites in Victoria and Calgary, and those findings may reveal additional facilitators and barriers to deprescribing in the hemodialysis population. 

Battistella says she and her team hope to promote deprescribing practices for even more people on hemodialysis by approaching provincial renal networks in Canada, as well as some health networks in the United States. “It’s exciting to see the project at this stage,” she says.  

To learn more about STOPMed-HD and access deprescribing resources for patients and clinicians, visit stopmedhd.ca.