Case Studies – Deprescribing

Case Studies – Deprescribing

Deprescribing is a best practice in medication handling and use among patients and caregivers. It refers to the process of tapering, discontinuing, withdrawing, or stopping a medication to manage polypharmacy and consequently improve the health outcomes of the patients (Wu et al., 2021). This paper analyzes deprescription through the lens of four patient case scenarios.

Patient 1

The case is of a 36-year-old male presenting to the clinic with a prescription for an opioid analgesic. The medication was prescribed three years ago by his PCP for a work accident. He is also on clonazepam for relaxation and panic attacks. It was determined that the best course of action is to remain on the opioid medication.

There are significant health concerns with the concomitant use of clonazepam and opioid analgesics. Taking clonazepam with opioid analgesics may result in severe side effects such as respiratory depression, drowsiness, coma, and even death. Caution should thus be taken to avoid using the two medications in combination.

To address these concerns, the patient should be educated against using the two medications concomitantly. He should be told that taking the two medications can cause significant harm to him due to their potential to cause CNS depression. Also, he risks developing breathing problems, coma, and even dying when he takes the two medications together.

The process of tapering off clonazepam is done systematically to prevent possible withdrawal effects. According to Wang et al.(2023), a dose reduction of 0.25mg/ week for patients on intermediate use of the medication can significantly reduce the chances of developing withdrawal effects. Likewise, for patients on long-term use of the medication, a dose reduction of 25% each quarter of the withdrawal period can significantly reduce the chances of developing withdrawal effects. This way, the patient is less likely to experience withdrawal effects.

To manage her anxiety, the patient can be initiated on trazodone. Trazodone has minimal drug interactions with opioid analgesics but is still effective against panic attacks. Patients on opioid analgesics can thus be started on low-dose trazodone for the management of their panic attacks. Trazodone is usually started at doses of 75 mg once daily. At this dose, the therapeutic effects of the drug are still optimal, with minimal drug interactions and side effects (Melaragno, 2021).

A legal consideration when starting the patient on trazodone is informed consent. An informed consent should be sought from the patient before switching the medications. Likewise, the caregiver demonstrates ethical practice by switching these medications as the switch ensures maximal medication safety with maintained clinical benefits per the provisions of beneficence. A social consideration when prescribing this medication is its potential for addiction and dependency. Caregivers, in this respect, should prescribe the medication judiciously and periodically assess the patients for addiction.

Patient 2

The case is a 42-year-old female on alprazolam for her panic attacks. She has been in remission and has been attempting to taper the dose. She, however, experiences withdrawal effects anytime she attempts to taper the dose, and is wondering how to taper the BDZ dose safely.

Inappropriate tapering of alprazolam can result in withdrawal effects. The common withdrawal symptoms of alprazolam include increased anxiety, insomnia, memory problems, and fatigue. These symptoms are often experienced selectively and may last weeks to months.

The patient should be notified of the harmful effects of acutely stopping alprazolam. In this respect, she should be educated on the post-acute symptoms, such as abnormal body sensations, such as muscle twitching and stiffness. If not addressed, she may progress to develop anxiety, insomnia, fatigue, and even memory problems. The common but less serious side effects include abnormal body sensations such as muscle twitching, stiffness, and fatigue. The symptoms that are a cause of concern include memory loss and depression. These symptoms can result in significant health deterioration, warranting care intervention.

Due to the patient’s history of experiencing withdrawal side effects when tapering alprazolam, converting her to longer-acting benzodiazepines may be necessary. Diazepam and clorazepate are long-acting benzodiazepines that maintain effectiveness in managing panic attacks. They may be used instead of alprazolam.

Diazepam is usually initiated in low doses to manage panic attacks. The patient in the case presented can benefit from a 2mg dose taken every 12 hours. Doses should be increased when the optimal response is not achieved with the starting dose. Diazepam can be tapered through weekly reductions of up to 4mg, depending on the total daily dose administered to the patients. For patients on a 40mg daily dose, dose decrements of 2-4mg are recommended until the patient is on 20mg. At 20mg, dose reductions of 1-2mg every week are recommended to prevent withdrawal effects (Reid Finlayson et al., 2022).

Patient 3

The case is of a 24-year-old female on lorazepam for her anxiety. She recently found that she is nine weeks pregnant and is wondering whether she could continue the medication. She has not had trials with other medications. She plans to breastfeed exclusively for the first six months.

Lorazepam is highly effective in managing anxiety. Its use in pregnancy has, however, been controversial. In the first trimester, the use of lorazepam is highly discouraged, and the medication should only be used when the benefits outweigh the risks. However, it is relatively safe during the second trimester. Long-term use of lorazepam, especially in the third trimester, has been shown to cause drowsiness in the unborn baby. Likewise, the baby is at risk of developing withdrawal symptoms when born to a mother on long-term use of lorazepam. Postpartum, the use of lorazepam does not cause significant side effects to the child at normal maternal doses (Lin et al., 2022).

Selective serotonin reuptake inhibitors (SSRIs) are first-line in the management of generalized anxiety disorders. They are a viable alternative for lorazepam in the patient in the case presented.  Citalopram is a safe SSRI in pregnancy. This medication is effective in managing GAD in pregnant women. The potential risk when using this medication is preterm delivery and low birth weight for the baby. The common side effects of citalopram include GI disturbances, fever, sweating, irregular heartbeat, hallucinations, and loss of coordination. Citalopram passes through the breast milk in small amounts and can be used safely among breastfeeding mothers.

Lorazepam is discontinued gradually to prevent withdrawal effects. A weekly dose reduction of 25-30% and then to 5-10% can significantly reduce the chances of withdrawal (Wang et al., 2023). The common and less serious withdrawal symptoms of lorazepam include sleep disturbances, irritability, hand tremors, and difficulty concentrating. The more serious side effect that warrants medical intervention is confusion.

Untreated anxiety has profound effects on pregnant women. It can result in preterm birth, early gestational age, preeclampsia, smaller head circumference of the baby, and low birth weight (Mahini et al., 2023). The mother should be told that she puts herself and her baby at risk when she leaves her anxiety unmanaged. The fetus may be born preterm or earlier during the gestational period. The fetus may also have a smaller head circumference and a low birth weight. It is thus important that her anxiety is managed.

Patient 4

The case is of a 71-year-old male who is reportedly experiencing memory loss. He is forgetful and seems to be tripping on things or walking into the wall despite having lived in the same homestead for the past 35 years. He is on metoprolol, omeprazole, clonazepam, and levothyroxine. Her daughter is wondering whether he is having dementia and should be initiated on dementia medications.

BDZs may have untoward effects on older adults. Their use may result in significant cognitive impairments, increased confusion and risk of falls, lethargy, and respiratory depression. The patient, in the case presented, should be notified of the common side effects of using this medication among elderly patients. They should be told that continuing benzodiazepines places the patient at risk of falls and confusion and may impair their mobility.

To evaluate the patient for the identified side effects, caregivers should assess any sudden cognitive or mobility changes in the patient. Mobility changes, such as tripping, may suggest benzodiazepine toxicity. Cognitive changes, such as the confused state, may also suggest BDZ toxicity.

The process of tapering off clonazepam is done systematically to prevent possible withdrawal effects. A dose reduction of 0.25mg/ week for patients on intermediate use of the medication can significantly reduce the chances of developing withdrawal effects. Likewise, for patients on long-term use of the medication, a dose reduction of 25% each quarter of the withdrawal period can significantly reduce the chances of developing withdrawal effects (Wang et al., 2023). This way, the patient is less likely to develop withdrawal effects.

Not tapering off the dose of clonazepam may result in withdrawal effects for the patients. The common and less serious withdrawal symptoms of clonazepam include anxiety, insomnia, and muscle aches. The more serious withdrawal symptom of clonazepam that warrants care intervention is depression.

References

Lin, Y., Chen, M., Chang, Y., Chen, L., Hsiung, C. A., & Wu, S. (2022). Prevalence of exposure to benzodiazepines among pregnant women in Taiwan: A Nationwide Longitudinal Study. Journal of Sleep Research, 31(6). https://doi.org/10.1111/jsr.13678

Mahini, E., Hakimi, S., Shahrokhi, H., Salahi, B., Baniadam, K. O., & Ranjbar, F. (2023). Evaluation of factors related to maternal anxiety during pregnancy among women referred to Tabriz Primary Care Centers. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-04823-8

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From First-line options to treatment resistance. FOCUS, 19(2), 145–160. https://doi.org/10.1176/appi.focus.20200048

Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823. https://doi.org/10.1177/20451253221082386

Wang, Y., Wilson, D. L., Fernandes, D., Adkins, L. E., Bantad, A., Copacia, C., Dharma, N., Huang, P.-L., Joseph, A., Park, T. W., Budd, J., Meenrajan, S., Orlando, F. A., Pennington, J., Schmidt, S., Shorr, R., Uphold, C. R., & Lo-Ciganic, W.-H. (2023). Deprescribing strategies for opioids and benzodiazepines with emphasis on concurrent use: A scoping review. Journal of Clinical Medicine, 12(5), 1788. https://doi.org/10.3390/jcm12051788

Wu, H., Kouladjian O’Donnell, L., Fujita, K., Masnoon, N., & Hilmer, S. N. (2021). Deprescribing in the older patient: A narrative review of challenges and solutions. International Journal of General Medicine, Volume 14, 3793–3807. https://doi.org/10.2147/ijgm.s253177

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

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 daughterthe potential 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.