Regular MedShadow readers are probably familiar with deprescribing–the method of reducing the quantity or dose of the drugs the person is taking. MedShadow has written about this issue before. While reducing medication dosage is straightforward, the actual procedure of stopping prescribing and balancing risks with benefits is a bit more complicated. Certain medications can cause withdrawal symptoms, and tapering could take some time.
The Therapeutics Initiative at the University of British Columbia (UBC) hosts an array of webinars featuring healthcare professionals sharing personal stories of their patients who were prescribed medications that they could reduce and the consequences when they could do so. To make deprescribing more real, healthcare professionals are telling the stories of their patients.
24 Pills a Day and Living in Bed
Shirley Samuel-Haynes, MD, a family doctor from Edmonton, Alberta, felt lost the first time she met Erin. Erin was aged 89 when they first met in the autumn of 2022. She was tired and couldn’t speak other than to say she was preparing to pass away before Christmas of the same year.
Erin was a person who spent the majority of her time in her bed. She was in a facility for long-term care where meals were delivered to her rooms. She’d been given various medications and supplements to treat Type 2 diabetes, atrial fibrillation, hypothyroidism, and chronic Obstructive Pulmonary Disorder (COPD).
“She simply wanted to leave for herself. I was left feeling depressed since I believed I could assist, but she kept pushing me away,” Samuel-Haynes said during the presentation.
The First Step Was Obvious: Avoid Spironolactone Dehydration
Because Erin could not find the motivation or motivation to speak with Samuel-Haynes about how she was feeling, Samuel Haynes started by asking for bloodwork. When the results came back, Erin’s potassium and sodium levels were clearly off. The potassium levels in her were incredibly high, and can lead to nausea, weakness, and heartbeats. One of the medicines Erin was recommended, spironolactone, is recognized to cause dehydration as well as high potassium levels. The primary reason she was given the medication was to treat low potassium levels.
“The answer was obvious. Stop the spironolactone.” said Samuel-Haynes.
Rethinking the Purpose of Treatment
A week later, Erin returned. Erin didn’t gain Olympian strength; however, she felt more energized and ready to speak about her treatment. Samuel-Haynes started asking Erin questions about what she was expecting from her treatment and what her objectives might be.
During two visits over two appointments, it was clear that Erin had two primary objectives. First was to be at ease, and the other was to have the energy and focus to talk with her parents.
“She was fearful about losing this ability,” stated Samuel-Haynes.
Samuel-Haynes suggested that instead of attempting to treat or prevent the disease, she adopt a palliative approach, which means she’d concentrate less on treatment that can reverse the illness and more on how Erin was feeling.
Palliative Care Sometimes Means Less Treatment
Erin was taking four different medications to treat Type 2 diabetes, yet her A1C–a measure for blood sugar level over time – remained high and was causing symptoms. The diabetes medications semaglutide, sitagliptin met, formin, and empagliflozin are well-known to trigger adverse effects like nausea, which is a sign Erin claimed she experienced.
Samuel-Haynes suggested that Erin trade among the four drugs instead of using insulin to lower her blood pressure. She added that any changes in dose would be based on the way Erin felt rather than her A1C reading.
Then, they began to talk about her vitamin intake. The woman was taking a multivitamin, a magnesium supplement, a B12 supplement, and a supplement with vitamin D. Samuel-Haynes explained that they had removed the vitamin D supplement and the multivitamin, both of which were recommended to prevent any future issues, such as weakening bones however, she “continued the ones she thought were helping with her symptoms.”
Restarting the spironolactone after her potassium levels fell and fluid accumulated within her abdomen was necessary. However, Erin reduced the number that she is taking in half. Not only did she get to celebrate Christmas in 2022, but also, in February 2023, she revealed to Samuel-Haynes that she was anticipating visits from her great-grandchildren in the summer. She added “I take very few pills now, thank goodness.”