Case Studies – De-Prescribing

Case Studies – De-Prescribing

De-prescribing involves gradually reducing, halting, or changing existing treatments with the goal of reducing harm and improving quality of life. This practice is very important in avoiding polypharmacy, minimizing drug complications, and improving patient’s status. In order to support the de-prescribing process, it is crucial to take several factors into consideration, to involve patients, as well as to take a systematic approach. This paper aims to present the role of de-prescribing based on four patient cases by describing approaches applicable to safe medication discontinuation and replacement.

Patient 1: A 36-Year-Old Male on Opioids and Clonazepam

Concerns about Remaining on Opioids and Clonazepam

Some complications connected with the long-term application of opioids and clonazepam are tolerance, dependence, cognitive changes, and overdose. Taking these drugs together only increases the risk of respiratory depression and sedation, which can be fatal. This is because the patient has severe and persistent pain and anxiety, and pain management should not jeopardize their safety.

Patient Education on Risks

The patient’s medical history should be assessed, and the risks of continued use of both medications should be discussed with him. Explaining to him the fact that the use of opioids on a long-term basis creates physical dependence and provides diminished pain control is necessary and that, similarly, long-term use of clonazepam leads to the development of tolerance, dependence, and cognitive impairment (Dowell et al., 2022). Emphasis on the possible interaction between these medications and the risks involved, namely severe sedation and respiratory depression that could lead to a fatal outcome, is also important.

Tapering Clonazepam

The reduction plan is crucial when it comes to tapering off clonazepam in order to avoid unwanted side effects. As suggested by Basit and Kahwaji (2020), the dose should be lowered by 0.25 mg every 2-4 weeks, observing the patient for withdrawal symptoms such as anxiety, insomnia, and irritability. The tapering schedule should be adjusted depending on the patient’s response, particularly if withdrawal symptoms are noted. Along with the tapering plan, other effective approaches, including CBT, could also be employed to address anxiety during the process of the tapering. This can offer help and enhance the particular end result of the patient.

Alternative Medication for Panic Attacks

An SSRI such as sertraline should be prescribed to the patient for panic attacks as this is safer in the long run than benzodiazepines. In contrast to tricyclic antidepressants, SSRIs have no dependence potential or cognitive side effects and can be taken in the long term.

Starting New Medication

Initial side effects can be minimized, and patient compliance can be enhanced by starting at a low dose of 25 mg/day with gradual uptitrations to the effective dose of 50-100 mg/day. These types of patients need periodic follow-up visits to determine the effectiveness and side effects of the treatments.

Legal, Ethical, or Social Consideration

A legal consideration in this context is doing proper consultations and establishing informed consent. The patient needs to comprehend the relative efficacy as well as the potential adverse effects occurring when discontinuing clonazepam and commencing an SSRI. Recording the conversation with the patient and the patient’s consent to the plan of treatment is recommended. Furthermore, the social issue to be concerned with may be the patient’s working capacity and ability to carry out daily activities without the sedation of clonazepam. Such an approach might allow for minimizing adherence-related problems in the transition between treatments and general enhancement of adherence to the new treatment plan.

Patient 2: A 42-Year-Old Female on Alprazolam

Common Withdrawal Symptoms from Alprazolam

Some of the symptoms associated with withdrawal from alprazolam are mild, while others are severe. Some of the most frequent signs are anxiety, sleeplessness, nervousness, and muscle aches. Other severe effects are seizures, hallucinations, and psychotic disorders, which should be addressed by a doctor.

Patient Education on Withdrawal Symptoms

Educating the patient about the spectrum of withdrawal symptoms is vital. Explaining that while mild symptoms like anxiety and insomnia are expected, severe symptoms such as seizures or hallucinations are serious and necessitate urgent medical care is also very crucial. The last is to provide reassurance and support, emphasizing the importance of not abruptly stopping the medication.

Conversion to a Longer-Acting Benzodiazepine

The first recommendation is to transition the patient to diazepam, a longer-acting benzodiazepine, which facilitates a smoother tapering process due to its extended half-life. This assists in keeping higher concentrations of the drug in the body, thereby cutting instances of withdrawal symptoms.

Tapering Plan

This is how to change the daily dose of alprazolam to an equivalent dose of diazepam. For instance, 1 mg of alprazolam is equivalent to 10 mg of diazepam; 100 mg of carbamazepine is approximately equal to 600 mg of phenobarbital. In accordance with (George & Tripp, 2022) begin the patient on the equivalent dose of diazepam and decrease this by 10-20% each week, depending on response as well as avoidance of withdrawal symptoms: avoid daily fluctuations by making dose changes gradual and only at set intervals. This is also critical since the patient has withdrawal signs, and giving him or her techniques like relaxation and mindfulness to cope with anxiety throughout the process of tapering is important.

Patient 3: A 24-Year-Old Female on Lorazepam

Risks, Benefits, and Side Effects of Continuing Lorazepam During Pregnancy and Postpartum

Lorazepam use during pregnancy means potential adverse outcomes like congenital anomalies, neonatal abstinence syndrome, and respiratory difficulties in the newborn. However, if anxiety is poorly managed in a mother, it can contribute to poor prenatal care and adverse pregnancy outcomes (Creeley & Denton, 2019). The continued use of lorazepam has several advantages that include: keeping the mother psychologically fit to continue caring for herself and her unborn child. However, these benefits have to be enjoyed with caution based on the following side effects.

Alternative Medications for Generalized Anxiety Disorder

Cognitive-behavioral therapy (CBT) should be employed first rather than medications since it does not have any side effects. In cases where medication is required, there are drugs such as sertraline and fluoxetine, which are among the selective serotonin reuptake inhibitors that show mild risks in pregnancy (Nakao et al., 2021). These drugs are efficient in treating anxiety and present fewer risks to pregnant women as compared to benzodiazepines. Also, Buspirone, an anxiolytic of the non-benzodiazepine type, can be included as it is safer during pregnancy.

 Tapering off Lorazepam

To discontinue lorazepam safely, a gradual taper is necessary. (Wang et al., 2023) recommends reducing the dose by 0.25 mg every 1-2 weeks to minimize withdrawal symptoms. A discussion with the patient on the side effects, which may include rebound anxiety/insomnia, as well as the serious side effects that are likely to require the attention of the doctor, such as seizures, is important. Additionally, creating a long-term support plan that would consist of weekly or bi-weekly counseling sessions and stress-reducing exercises will be of much help to the patient when it comes to coping with episodes of anxiety while on a tapering process or even during the pregnancy period.

Risks of Untreated Anxiety During Pregnancy

I would explain to the patient that untreated anxiety can lead to increased stress, poor prenatal care, and adverse effects on fetal development. It, therefore, is crucial to manage anxiety effectively to ensure both maternal and fetal well-being. Providing reassurance that there are safe and effective ways to manage anxiety during pregnancy is important. Further, there should be an emphasis on the importance of regular follow-ups and mental health support to monitor and manage her anxiety throughout the pregnancy.

Patient 4: A 71-Year-Old Male on Benzodiazepines

Side Effects of Benzodiazepines in the Elderly

Some of the side effects of benzodiazepines are confusion, propensity to falls and fractures, and delirium, which are more likely to affect elderly patients. These side effects can thus compromise their quality of life and their level of self-sufficiency. Furthermore, it is useful only in short-term treatment, and prolonged usage leads to worsening of dementia symptoms as well as the possibility of an overdose.

Evaluation of Patient for Side Effects

I will conduct a more comprehensive assessment, including a neuropsychiatric assessment, a cognitive screen, and the fall risk assessment test. This makes it possible to know how much of the benzodiazepines are still affecting the patient during the course of the tapering. This should also include the medication review exercise to ensure that they do not contravene any precautions, such as drug interactions.

Tapering Plan for Clonazepam

First, develop a tapering plan that reduces the clonazepam dose by 0.25 mg every 2-4 weeks (Bounds & Nelson, 2023). The patient needs to be closely monitored for withdrawal symptoms, and the rate of tapering needs to be adjusted depending on the patient’s reaction. Considering the patient’s age and potential vulnerability to withdrawal, it is necessary to gradually taper the dose. If these symptoms persist, then the clonazepam should be replaced by another anxiolytic agent that has fewer sedative properties.

Side Effects of Tapering Off Clonazepam

It will be crucial to discuss with the patient, as well as with his daughter, about the possible adverse reactions of stopping clonazepam gradually. These include generalized anxiety, irritability, and sleep disturbances. Certain side effects are more severe and include shaking or trembling, confusion, and even seizures, which should be reported to the doctor at once. Make sure that they know when they need to go to the hospital. Lastly, education regarding possible treatments for anxiety symptoms apart from pharmacotherapy, like CBT, while in the dosing down process, will be very helpful.

Conclusion

De-prescribing, though widely practiced, is a critical aspect of medicine administration, especially for patients with extended medication regimens and numerous dangers associated with taking the drugs. Close monitoring and gradual dose reduction, as well as extensive patient counseling, should be the strategies of choice due to the withdrawal symptoms’ potential severity. Special attention to patients, their perceptions, and other specific aspects will improve the quality of services and patients’ well-being in general. And most importantly of, constant follow-up and supervision should be done in order to guarantee the success of the de-prescribing process and counter arising problems.

References

Basit, H., & Kahwaji, C. I. (2020). Clonazepam. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556010/

Bounds, C. G., & Nelson, V. L. (2023). Benzodiazepines. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470159/

Creeley, C., & Denton, L. (2019). Use of prescribed psychotropics during pregnancy: A systematic review of pregnancy, neonatal, and childhood outcomes. Brain Sciences, 9(9), 235. https://doi.org/10.3390/brainsci9090235

Dowell, D., Ragan, K., Jones, C., Baldwin, G., & Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR. Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1

George, T. T., & Tripp, J. (2022). Alprazolam. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30844192/

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral Therapy for Management of Mental Health and stress-related disorders: Recent Advances in Techniques and Technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

Wang, Y., Wilson, D. L., Fernandes, D., Adkins, L. E., Bantad, A., Copacia, C., Nilay Dharma, Huang, P.-L., Joseph, A., Tae Woo Park, Budd, J., Senthil Meenrajan, Orlando, F. A., Pennington, J., Schmidt, S., Shorr, R. I., Uphold, C. R., & Wei-Hsuan Lo-Ciganic. (2023). Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. Journal of Clinical Medicine, 12(5), 1788–1788. https://doi.org/10.3390/jcm12051788

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What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?

In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of the Required Learning Resources in this course.

Note: APA style format guidelines will apply.

Patient Examples:

Patient 1: A 36-year-old male presents to your office having been prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined that the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.

Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission, and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.

Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks of gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety, as lorazepam has been effective.

Patient 4: A 71-year-old male who comes to see you at the insistence of his daughter. His daughter expresses concern about memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE FOR THIS ASSIGNMENT:
Review the assigned Learning Resources for this week.
Review the definitions presented in your text and resources for de-prescribing and tapering.
Consider the importance of de-prescribing.
Based on the example(s) provided, consider how you might de-prescribe a patient.
THE ASSIGNMENT
Answer the following questions using the patient examples described above.

Patient 1

What are the concerns of the patient remaining on the opioid medication and clonazepam?
How might you educate the patient about these risks and concerns?
The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

How would you instruct the patient to taper off clonazepam?
What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
How would you start the new recommended psychotropic medication for the patient?
Discuss one legal, ethical, or social consideration with the treatment plan.

Patient 2

The patient reports withdrawal symptoms when previously tapering off the alprazolam. What are common withdrawal symptoms from this medication?
Provide the patient education on withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt the patient should seek medical attention.
Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?
What is the dose you would prescribe, and how would you taper off the medication?

Patient 3

Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.
Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breastfeed for 6 months postpartum.
The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.
The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.

Patient 4

Review potential side effects for the elderly on benzodiazepines, providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
How would you evaluate the patient for these side effects?
The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
Review with the patient and daughter pthe otential side effects of tapering off the medication. Review with them common side effects to more serious side effects, and when to seek medical attention.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Walden Writing Center Sample Paper Links to an external site. provides an example of those required elements.