Polifarmácia, medicamentos potencialmente inapropriados e desprescrição em pacientes internados sob cuidados paliativos em fase final de vida

Abstract

INTRODUCTION: With the establishment of the concept of palliative care (PC), the attention given to patients at the end of life must be personalized and based on a particular care plan. The use of medications should be addressed, avoiding the use of potentially inappropriate medications (PIMs), and polypharmacy. Prescribed medications should be reevaluated frequently, and those which no longer have benefit for the patient should be discontinued (deprescription). Deprescribing of medications, however, is rarely performed. In this context, it is assumed that the role of a multidisciplinary palliative care team is fundamental in providing guidance on the risks and benefits associated with medications, and assisting in the process of discontinuing PIM. This topic is very relevant, but still understudied. OBJECTIVES: 1- To describe the use of medications in patients at the end of life in the 90 and 7 days before death, as well as on the day of death; 2- to evaluate the prevalence of polypharmacy and the prescription of PIM; 3- to evaluate the deprescription of PIM after the assessment performed by the PC team. METHODS: Retrospective cohort study. Data were collected at Hospital Regional de Ceilândia (HRC), in Distrito Federal, Brazil, in patients admitted between January 2017 and December 2020. All inpatients who were evaluated by the PC team and considered with indication for exclusive/proportional PC (without indication for invasive measures) were included. Medical records were reviewed, retrieving the medications used by the patients 90 days before death, 7 days before death and on the day of death. In addition, medications prescribed the day before and the day after the PC team evaluation were also listed, and those considered PIMs according to available literature and that were deprescribed after this visit were analyzed. For comparison of continuous dependent variables the paired T-test was used for parametric variables and the Friedman or Wilcoxon tests for nonparametric variables. For comparison of categorical variables the Cochran's Q test or the McNemar test was used. All statistical tests were performed in Stata software version 15.1. p values < 0.05 were considered significant. RESULTS: 97 patients admitted to the HRC in the period were included in this study. This population was predominantly elderly (median age 76 years (IIQ 64 - 83)), with presence of multiple comorbidities (Charlson Comorbidity Index ≥3 in 66 patients, (68.1%)), mostly admitted for sepsis (29 patients (29.9%)) and cancer (25 patients (25.8%)). The total number of medications had a significant increase (p < 0.001), with a median of 4 medications 90 days before death (IQ25-75% 1 - 6), raising to a median of 9 medications 7 days before death (IQ25-75% 6 - 11) (p < 0.001), and a subsequent decreasing to a median of 7 medications (IQ25-75% 5 - 10) on the day of death (p = 0.001). The increase in the prevalence of polypharmacy was also significant (p < 0.001), varying from 39% 3 months before death, with an increase to 87% seven days before death (p < 0.001) and a decrease to 76% on the day of death (p = 0.004). The prevalence of MPI prescription had statistically significant variation (p < 0.001), with a median of 2 MPI prescribed 90 days before death (IQ25-75% 0 - 3), increasing to a median of 3 MPI 7 days before death (IQ25-75% 2 - 4) (p < 0.001), and decreasing to 2 MPI on the day of death (IQ25-75% 1 - 3) (p < 0.001). When we assess the PIM before and after the evaluation by CP team, we observed that this dropped from a median of 3 (IQ25-75% 2 - 4) to a median of 2 (IQ25-75% 1 - 4), a finding with no statistical significance (p = 0.18). When this evaluation is performed according to each class of MPI, there was a statistically significant reduction in the prescription of antithrombotic drugs (reduction from 77 prescriptions before the PC team evaluation to 70 prescriptions after the PC team evaluation, p = 0.02). CONCLUSION: Among patients hospitalized in palliative care and in end of life, the number of medications, the prevalence of polypharmacy PIMs use is high. After PC team evaluation there was not a statistically significant reduction in PIMs overall, but was a significant reduction on the prescription of antithrombotic drugs. Further studies are needed to develop strategies to promote effective deprescribing in this population.