Pharmacist-Led NSAID Deprescribing Program
Pharmacist-Led NSAID Deprescribing Program
Colton Sharp, Pharm. D., MBA, Walgreens Pharmacy | M Health Fairview Bethesda
Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed medications used both acutely and chronically to treat pain associated with inflammatory conditions, such as rheumatoid arthritis and osteoarthritis. Although they are very effective in relieving this pain, NSAIDs can be associated with adverse effects such as gastrointestinal (GI) bleeding and nephrotoxicity. Long-term use may lead to a multitude of problems, such as GI ulcers, acute kidney injury (AKI) or worsening of hypertension. The geriatric population is particularly at risk, as they are prone to medication-related adverse events. Deprescribing programs, which are provider-led protocols that gradually decrease doses and eventually lead to the discontinuation of medications, may be used to help avoid unnecessary risk and potential harm to patients. Studies of this sort are in abundance for many medication classes, however, NSAID deprescribing protocols lack specific evidence and guidance.
Objective: To compare and contrast the safety, efficacy, and economic benefits of standardized pharmacist-led deprescribing of NSAIDs versus usual care within an integrated healthcare system.
Study Design: This research was conducted via a retrospective, propensity score-matched cohort study designed to include elderly patients (≥65 years of age) who qualified for NSAID deprescribing. Eligible patients in the control group were matched to the intervention group via propensity score matching at a ratio of 4:1. Patients in the deprescribing group were assessed by a pharmacist and had their NSAID regimen deprescribed. This process typically included an initial 25-50% dose reduction with a two to four week follow-up, and adjustments made as needed. Pharmacists were also available to patients via a secure online messaging platform. Patients were followed for six months, until membership ended, or death, whichever occurred first. The effectiveness and safety outcomes measured the occurrence of three adverse events: GI bleeds, AKI, and exacerbation of pain triggering hospitalization or emergency room visit. In addition, the study also measured change in economic outcomes defined as change in monthly NSAID cost. Analysis of the study results included descriptive statistics, t-tests, chi-square tests, and conditional logistic regression models.
Results: Patients completing the study included 431 in the deprescribed group and 1,724 in the usual care (or control) group. The baseline characteristics were similar in each group. No significant differences were found between the groups for GI bleeds OR=0.65 [95% CI=0.36-1.16] P=0.15), AKI (OR=0.53 [95% CI=0.24-1.16] P=0.11), or economic impact (median change, IQR: -$0.29, -$2.37 to -$0.11 for deprescribed group; -$0.23, -2.59 to 0.00 for usual care group, P=0.054). However, the decrease in exacerbation of pain was found to be two-fold in the deprescribed group (OR=0.50[95% CI=0.33-0.77] P<0.01), a result that was shown to be statistically significant.
Limitations: A design limitation of this study includes its small sample size. Additionally, there were many factors that were not accounted for, such as lifestyle habits, diet, and over-the-counter NSAID or aspirin use. The study also did not account for the “intensity” of each patient’s given regimen, nor how that could have factored into the results. Finally, the patients were selected from a single integrated healthcare system, therefore extrapolating these results to the general population must be done with caution.
Conclusions: Although no statistically significant differences were found in the outcomes of GI bleeds, AKI, and economic impact, a significant decrease in exacerbation of pain was found among the deprescribing group. Therefore, this pharmacist-led NSAID deprescribing program appeared to cause minimal harm to the patients. Further long-term studies are needed to validate the results and generalizability of this study.
Key Point: Apharmacist-led NSAID deprescribing program appears to have minimal benefit in reduction of the adverse endpoints of the study, but also cause minimal detriment to patients’ quality of life. Further long-term follow-up studies are needed to determine the true benefits of these types of programs.
Rashid R, Chang C, Niu F, et al. Evaluation of a pharmacist-managed nonsteroidal anti-inflammatory drugs deprescribing program in an integrated health care system. J Manag Care Spec Pharm. 2020;26(7):918-24.