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Pharmacists’ contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis

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Abstract

Background

Consolidated and reliable evidence regarding the effectiveness of pharmacist interventions for deprescribing benzodiazepines in older outpatients is lacking.

Aim

This study evaluated and summarized the impact of pharmacist interventions on benzodiazepine deprescribing among older outpatients.

Method

A literature search was conducted until August 2022 in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials databases. The review included randomized controlled trials that assessed the impact of pharmacist interventions on deprescribing benzodiazepine in older outpatients. Two independent investigators conducted the study selection, data extraction, and risk of bias assessment. Meta-analyses were conducted using random-effect models in the RStudio software.

Results

A total of 893 records were identified. Five studies, including 3,879 patients, met the inclusion criteria and were included in the systematic review. All five studies used health education as an intervention strategy, and three also conducted medication reviews. There was no evidence of the pharmacist’s authority to modify prescriptions during benzodiazepine deprescribing. One study was classified as having a low risk of bias, whereas the other had some concerns or a high risk of bias. Three studies were included in the meta-analysis and a significant impact of pharmacist interventions on benzodiazepines deprescribing rates in older outpatients was observed (RR = 2.75 [95%CI 1.29; 5.89]; p = 0.04; I2 = 69%; low certainty of evidence).

Conclusion

Pharmacists may contribute to deprescribing benzodiazepines in older outpatients. Further studies are needed to increase the reliability of these findings.

PROSPERO registration number: CRD42022358563.

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References

  1. McCarthy M, Mak S, Kaufmann CN, et al. Care coordination needs for deprescribing benzodiazepines and benzodiazepine receptor agonists. Res Social Adm Pharm. 2022;18(4):2691–4. https://doi.org/10.1016/j.sapharm.2021.06.025.

    Article  PubMed  Google Scholar 

  2. Freire MBO, Da Silva BGC, Bertoldi AD, et al. Benzodiazepines utilization in Brazilian older adults: a population-based study. Rev Saude Publica. 2022;56:10. https://doi.org/10.11606/s1518-8787.2022056003740.

    Article  PubMed  PubMed Central  Google Scholar 

  3. van Beek JH, Kirkwood TB, Bassingthwaighte JB, et al. Understanding the physiology of the ageing individual: computational modelling of changes in metabolism and endurance. Interface Focus. 2016;6(2):20150079. https://doi.org/10.1098/rsfs.2015.0079.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Airagnes G, Pelissolo A, Lavallée M, et al. Benzodiazepine misuse in the elderly: risk factors, consequences, and management. Curr Psych Rep. 2016;18(10):89. https://doi.org/10.1007/s11920-016-0727-9.

    Article  Google Scholar 

  5. Naloto DC, Lopes FC, Barberato Filho S, et al. Prescription of benzodiazepines for adults and older adults from a mental health clinic. Cien Saude Colet. 2016;21(4):1267–76. https://doi.org/10.1590/1413-81232015214.10292015.

    Article  PubMed  Google Scholar 

  6. Fick DM, Semla TP, Steinman M, et al. American geriatrics society 2019 updated AGS beers criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674–94. https://doi.org/10.1111/jgs.15767.

    Article  Google Scholar 

  7. Ettcheto M, Olloquequi J, Sánchez-López E, et al. Benzodiazepines and related drugs as a risk factor in Alzheimer’s disease dementia. Front Aging Neurosci. 2020;11:344. https://doi.org/10.3389/fnagi.2019.00344.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738–47. https://doi.org/10.1111/bcp.12386.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Niznik JD, Collins BJ, Armistead LT, et al. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: a rapid review. Res Social Adm Pharm. 2022;18(6):2913–21. https://doi.org/10.1016/j.sapharm.2021.07.012.

    Article  PubMed  Google Scholar 

  10. Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Can Fam Physician. 2018;64(5):339–51.

    PubMed  PubMed Central  Google Scholar 

  11. Thillainadesan J, Gnjidic D, Green S, et al. Impact of deprescribing interventions in older hospitalised patients on prescribing and clinical outcomes: a systematic review of randomised trials. Drugs Aging. 2018;35(4):303–19. https://doi.org/10.1007/s40266-018-0536-4.

    Article  CAS  PubMed  Google Scholar 

  12. Bužančić I, Kummer I, Držaić M, et al. Community-based pharmacists’ role in deprescribing: a systematic review. Br J Clin Pharmacol. 2022;88(2):452–63. https://doi.org/10.1111/bcp.14947.

    Article  PubMed  Google Scholar 

  13. Ibrahim K, Cox NJ, Stevenson JM, et al. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr. 2021;21(1):258. https://doi.org/10.1186/s12877-021-02208-8.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Higgins JPT, Thomas J, Chandler J, et al (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook

  15. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906. https://doi.org/10.1136/bmj.n71.

    Article  PubMed  Google Scholar 

  16. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Dagnew SB, Binega Mekonnen G, Gebeye Zeleke E, et al. Clinical pharmacist intervention on drug-related problems among elderly patients admitted to medical wards of northwest Ethiopia comprehensive specialized hospitals: a multicenter prospective Observational Study. Biomed Res Int. 2022. https://doi.org/10.1155/2022/8742998.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Higgins JPT, Savović J, Page MJ, et al. Assessing risk of bias in a randomized trial. Cochrane Handb Syst Rev Interv. 2019. https://doi.org/10.1002/9781119536604.ch8.

    Article  Google Scholar 

  19. Guyatt GH, Oxman AD, Schünemann HJ, et al. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–2. https://doi.org/10.1016/j.jclinepi.2010.09.011.

    Article  PubMed  Google Scholar 

  20. Schünemann H, Brozek J, Guyatt G, et al, editors (The GRADE Working Group) (2013) GRADE handbook for grading quality of evidence and strength of recommendations. Available from: http://www.guidelinedevelopment.org/handbook. Accessed 12 Jan 2023.

  21. Veroniki AA, Jackson D, Viechtbauer W, et al. Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth Methods. 2016;7(1):55–79. https://doi.org/10.1002/jrsm.1164.

    Article  PubMed  Google Scholar 

  22. Schuller-Martínez B, Meza N, Pérez-Bracchiglione J, et al. Graphical representation of the body of the evidence: the essentials for understanding the evidence gap map approach. Medwave. 2021;21(3):e8164. https://doi.org/10.5867/medwave.2021.03.8164.

    Article  PubMed  Google Scholar 

  23. Ashworth N, Kain N, Wiebe D, et al. Reducing prescribing of benzodiazepines in older adults: a comparison of four physician-focused interventions by a medical regulatory authority. BMC Fam Pract. 2021;22(1):68. https://doi.org/10.1186/s12875-021-01415-x.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Evrard P, Henrard S, Foulon V, et al. Benzodiazepine use and Deprescribing in Belgian nursing homes: results from the COME-ON study. J Am Geriatr Soc. 2020;68(12):2768–77. https://doi.org/10.1111/jgs.16751.

    Article  PubMed  Google Scholar 

  25. Navy HJ, Weffald L, Delate T, et al. Clinical pharmacist intervention to engage older adults in reducing use of alprazolam. Consult Pharm. 2018;33(12):711–22. https://doi.org/10.4140/TCP.n.2018.711.

    Article  PubMed  Google Scholar 

  26. Roberts MS, Stokes JA, King MA, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51(3):257–65. https://doi.org/10.1046/j.1365-2125.2001.00347.x.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890–8. https://doi.org/10.1001/jamainternmed.2014.949.

    Article  CAS  PubMed  Google Scholar 

  28. Hernández-Prats C, López-Pintor E, Lumbreras B, et al. Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies. Res Social Adm Pharm. 2022;18(5):2748–56. https://doi.org/10.1016/j.sapharm.2021.06.023.

    Article  PubMed  Google Scholar 

  29. Balsom C, Pittman N, King R, et al. Impact of a pharmacist-administered deprescribing intervention on nursing home residents: a randomized controlled trial. Int J Clin Pharm. 2020;42(4):1153–67. https://doi.org/10.1007/s11096-020-01073-6.

    Article  PubMed  Google Scholar 

  30. Kua CH, Yeo CYY, Tan PC, et al. Association of deprescribing with reduction in mortality and hospitalization: a pragmatic stepped-wedge cluster-randomized controlled trial. J Am Med Dir Assoc. 2021;22(1):82–9. https://doi.org/10.1016/j.jamda.2020.03.012.

    Article  PubMed  Google Scholar 

  31. Lui E, Wintemute K, Muraca M, et al. Pharmacist-led sedative-hypnotic deprescribing in team-based primary care practice. Can Pharm J Ott. 2021;154(4):278–84. https://doi.org/10.1177/17151635211014918.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Eide E, Schjøtt J. Assessing the effects of an intervention by a pharmacist on prescribing and administration of hypnotics in nursing homes. Pharm World Sci. 2001;23(6):227–31. https://doi.org/10.1023/a:1015142211348.

    Article  CAS  PubMed  Google Scholar 

  33. Stevenson DG, Decker SL, Dwyer LL, et al. Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey. Am J Geriatr Psych. 2010;18(12):1078–92. https://doi.org/10.1097/JGP.0b013e3181d6c0c6.

    Article  Google Scholar 

  34. Malagaris I, Mehta HB, Goodwin JS. Trends and variation in benzodiazepine use in nursing homes in the USA. Eur J Clin Pharmacol. 2022;78(3):489–96. https://doi.org/10.1007/s00228-021-03244-4.

    Article  CAS  PubMed  Google Scholar 

  35. Pollmann AS, Murphy AL, Bergman JC, et al. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review. BMC Pharmacol Toxicol. 2015;16:19. https://doi.org/10.1186/s40360-015-0019-8.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Ribeiro PRS, Schlindwein AD. Benzodiazepine deprescription strategies in chronic users: a systematic review. Fam Pract. 2021;38(5):684–93. https://doi.org/10.1093/fampra/cmab017.

    Article  PubMed  Google Scholar 

  37. Yariv H. The case of pharmacist prescribing policy in Israel. Isr J Health Policy Res. 2015;4:49. https://doi.org/10.1186/s13584-015-0045-4.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Graham-Clarke E et al. Non-medical prescribing in the United Kingdom National Health Service: a systematic policy review. PLoS ONE. 2019;14(7):e0214630. https://doi.org/10.1371/journal.pone.0214630.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Conselho Federal de Farmácia. (2013). Resolução CFF nº 586, de 29 de agosto de 2013. Regula a prescrição farmacêutica e dá outras Providências. Diário Oficial da União, 29. Retrieved from: https://www.semesp.org.br/wpcontent/uploads/2013/09/res_CFF_586-ok.pdf. Accessed 20 Jan 2023.

  40. Ramos DC et al. Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals. Ciencia saude coletiva. 2022;27:3531–46. https://doi.org/10.1590/1413-81232022279.19972021.

    Article  PubMed  Google Scholar 

  41. Mudge A, Radnedge K, Kasper K, et al. Effects of a pilot multidisciplinary clinic for frequent attending elderly patients on deprescribing. Aust Health Rev. 2016;40(1):86–91. https://doi.org/10.1071/AH14219.

    Article  PubMed  Google Scholar 

  42. Sakakibara M, Igarashi A, Takase Y, et al. Effects of prescription drug reduction on quality of life in community-dwelling patients with dementia. J Pharm Pharm Sci. 2015;18(5):705–12. https://doi.org/10.18433/j37p5x.

    Article  PubMed  Google Scholar 

  43. Cross AJ, George J, Woodward MC, et al. Deprescribing potentially inappropriate medications in memory clinic patients (DePIMM): a feasibility study. Res Social Adm Pharm. 2020;16(10):1392–7. https://doi.org/10.1016/j.sapharm.2020.01.010.

    Article  PubMed  Google Scholar 

  44. Evrard P, Pétein C, Beuscart JB, et al. Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework. Implement Sci. 2022;17(1):17–41. https://doi.org/10.1186/s13012-022-01206-7.

    Article  Google Scholar 

  45. Carr F, Tian P, Chow J, et al. Deprescribing benzodiazepines among hospitalised older adults: quality improvement initiative. BMJ Open Qual. 2019;8(3):1–8. https://doi.org/10.1136/bmjoq-2018-000539.

    Article  Google Scholar 

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Funding

TARM received a scholarship from the Ministry of Health for the USP residency program in Clinical Pharmacy and Pharmaceutical Care. The authors have not received specific grants from public, commercial, or not-for-profit funding agencies.

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Authors and Affiliations

  1. Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Prof. Lineu Prestes, 580, Conj. das Químicas, Bloco 13, Cidade Universitária Butantã, São Paulo, Brazil

    Thiago Afonso Rodrigues Melo & Patricia Melo Aguiar

  2. Municipal Health Department, Multiprofessional Residency Program in Family and Community Health, João Pessoa, PB, Brazil

    Cleyton Oliveira Bezerra

  3. Capixaba Institute of Health Education, Research and Innovation, Vitória, ES, Brazil

    Brígida Dias Fernandes

  4. Department of Pharmacy, Federal University of Paraná, Curitiba, PR, Brazil

    Inajara Rotta

  5. Department of Pharmaceutical Sciences, Health Sciences Center, Federal University of Paraíba, João Pessoa, PB, Brazil

    Walleri Christini Torelli Reis

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  1. Thiago Afonso Rodrigues Melo
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Correspondence to Patricia Melo Aguiar.

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Melo, T.A.R., Bezerra, C.O., Fernandes, B.D. et al. Pharmacists’ contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis. Int J Clin Pharm 45, 1037–1049 (2023). https://doi.org/10.1007/s11096-023-01637-2

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