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Therapeutics Initiative Profile picture
@Drug_Evidence
Sep 15, 2022 • 10 tweets • 13 min read • Read on X
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🧵 Reducing #PrescribingCascades ⬇️

1/ What are #Prescribing Cascades?

1⃣ A drug is prescribed 💊
2⃣ #AdverseEvent occurs but is misinterpreted as a new medical condition ⚠️
3⃣Another drug is prescribed for the drug-induced adverse event 💊💊

ti.ubc.ca/letter138 #MedEd Image
2/ Anticholinergics ➡️ cognitive dysfunction ➡️ drugs for #dementia

#Anticholinergic 💊 block acetylcholinergic neurotransmission in the brain, impairing cognition & memory

Can lead to new Rx or ↗️ acetylcholinesterase inhibitor doses

ti.ubc.ca/letter138 #MedEd #FOAMed Image
3/ Drugs for #dementia ➡️ incontinence ➡️ anticholinergics

Conversely, AChE-I can cause urinary or fecal incontinence, that may "cascade" to prescription of an #anticholinergic

👉🏽 full Letter here: ti.ubc.ca/letter138

#MedEd #PrescribingCascades #MedTwitter Image
4/ Anticholinergics ➡️ dyspepsia/reflux (“GERD”) ➡️ #PPIs

#Dyspepsia or heartburn due to delayed gastric emptying can be mistaken for spontaneous #GERD

This association was suggested as possible cascade in a study evaluating longterm Rx of #PPIs

ti.ubc.ca/letter138 #MedEd Image
5/ Anticholinergics ➡️ constipation ➡️ laxatives

Drug-induced constipation is well recognized, an association confirmed by a 2021 systematic review

👉🏽Full Letter: ti.ubc.ca/letter138

#MedEd #prescribing #medsafety #ptsafety Image
6/ Calcium channel blockers (CCB) gabapentin/pregabalin ➡️ edema ➡️ diuretics

✅CCB cause dose-dependent edema in up to 30% of older pts

✅Reducing or 🛑 CCB can be preferable to adding furosemide, given multiple #AdverseEffects of loop diuretic

ti.ubc.ca/letter138 #MedEd Image
7/ Drug-induced movement disorders ➡️ Parkinson's meds 💊

Most #antipsychotics & some #antidepressants block dopamine receptors or cause movement disorders by other means

Such #AdverseEvents can be mistaken for Parkinson's

ti.ubc.ca/letter138 #PrescribingCascades Image
8/ Drug-induced #HTN ➡️ antihypertensive 💊

About 15% of US adults (19% of ppl w/ HTN) take a drug that can ↗️ blood pressure

#Antidepressants (8.7% of adults) & Rx #NSAIDs (6.5%) were most frequent candidates for under-recognized #prescribing cascades

ti.ubc.ca/letter138 Image
9/ Conclusions

✅Prescribing cascades cause avoidable #polypharmacy & harms

✅Prevent by careful indication-based prescribing & screening for cascades during #MedicationReviews

✅Utilize expert #pharmacist or medical consultation when available

ti.ubc.ca/letter138 #MedEd Image
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More from @Drug_Evidence

Therapeutics Initiative Profile picture
Oct 10
🧵Safe diabetes treatment for older adults
👉🏽

1/ Risks of harms from side effects

⚠️For diabetes meds, low blood sugar is one of the most important side effects
⚠️Sulfonylureas & insulins are the drugs most likely to cause low blood sugar

#ptsafety #T2DM ti.ubc.ca/letter151Image
2/ Isn’t low A1c always good?

Trials w/ tens of thousands of pts looked at effects of achieving A1c < 7% for older ppl & found:

❌ No benefit to A1c < 7%, compared w/ more relaxed value of 7.5-8%
⚠️ A1c < 7% raises chance of dangerously low blood sugar

ti.ubc.ca/letter151Image
3/ What glycemic target to choose for older adults?

@ChooseWiselyCA provides the following reasonable glycemic 🎯:

🟢Healthy older ppl w/ long life expectancy: 7-7.5%
🟡Moderate comorbidity, life expectancy <10 yr: 7.5-8%
🔴Multiple morbidities, shorter life expectancy: 8-8.5% Image
Read 8 tweets
Therapeutics Initiative Profile picture
Nov 30, 2022
🧵 How well do you know your dopamine antagonists? 💊💊

1/ Using these drugs safely requires that clinicians & patients appreciate their important #AdverseEffects, which are not always well understood

👉🏽ti.ubc.ca/letter139

#MedEd #prescribing #deprescribing #medsafety
2/ #AdverseEffects may include:

⚠️ Drug-induced #Parkinsonism
-↘️ or slowed movements, rigidity/tremor/unsteadiness, facial expression loss

⚠️ #Akathisia
-intense internal restlessness or desire to move (which may be mistaken for anxiety)

👉🏽Pt videos: ti.ubc.ca/letter139
3/ #AdverseEffects may include:

⚠️Acute dystonic reaction
-sudden, involuntary, often painful muscle spasm

⚠️Dyskinesia
-repetitive, involuntary movements...can be associated with cognitive decline

👉🏽Pt experience videos: ti.ubc.ca/letter139

#MedEd #ptsafety #drugsafety
Read 7 tweets
Therapeutics Initiative Profile picture
Nov 3, 2022
🧵 Reducing unnecessary use of proton pump inhibitors (PPIs)

1/ Many people take #PPIs but up to 50% don’t have a good reason to take them > 8 wks

Read on for tips on how you as a clinician can work together with pts to decide if/how to 🛑 or reduce PPIs

#MedEd #deprescribing Image
2/ Does this person need #PPIs long-term (> 8 wks)?
 
Find pts who might not need long-term PPI:
1⃣ Flag refill requests
2⃣ Use a poster or video in waiting room
3⃣ Run EMR report
 
This @bmj_latest article has more tips to help with #deprescribing PPIs: bit.ly/3fisHsT
3/ Indications for long-term #PPIs include:

Barrett’s esophagus, previous bleeding ulcer, chronic NSAID use w/ mod/severe bleed risk, severe esophagitis, Zollinger-Ellison syndrome
 
If no indication for long-term PPI + no ongoing upper GI symptoms, discuss poss #deprescribing Image
Read 7 tweets
Therapeutics Initiative Profile picture
May 26, 2022
THREAD: #Prescribers, how do YOU respond to Conflicts of Interest (COI)? 👀

1/8 This thread looks at the issues highlighted in our TI Therapeutics Letter on COI

👉🏼Full Letter: ti.ubc.ca/letter136

#ConflictofInterest #MedEd #MedicalEthics
2/8 Kirsten is a clinical pharmacist attending a primary care conference👩🏽‍⚕️

When a keynote speaker reports financial relationships💰with several drug companies, Kirsten takes note🤨

Find out why she prefers #MedEd free of commercial sponsorship: ti.ubc.ca/letter136
3/8 Key Opinion Leaders (KOLs)

It's common practice to cultivate “expert” KOLs who are crucial to market success💵of a new drug

Payments to KOLs are reported in USA but similar disclosure does NOT exist in Canada
go.nature.com/39XdVVq

#FinancialInterests #ConflictofInterest
Read 9 tweets
Therapeutics Initiative Profile picture
May 16, 2022
THREAD: Online Portraits for BC family physicians

1/7 UBC’s Therapeutics Initiative now has Online #PrescribingPortraits: ti.ubc.ca/portrait

✅ Timely evidence
✅ Personalized, confidential prescribing data
✅ Recommendations to support

#BetterPrescribing & #BetterHealth Image
2/7 Why have a #PrescribingPortrait?

"How do I prescribe compared to others or to evidence standards?"

✅Portrait does NOT tell individual doctors how to practice
✅Portrait DOES promote optimal prescribing based on best available evidence

More here: ti.ubc.ca/portrait Image
3/7 BC family physicians: How do you prescribe ACEIs and ARBs for #hypertension?

✅Register for your Online #PrescribingPortrait: ti.ubc.ca/portrait

✅View a sample portrait on prescribing of antihypertensives: ti.ubc.ca/2022/01/28/ace…

#BetterPrescribing #MedEd Image
Read 8 tweets
Therapeutics Initiative Profile picture
Mar 28, 2022
THREAD: How best to treat Urinary Tract Infections?

1/6 Our new TI Therapeutics Letter 135 describes the best approach for treating symptomatic, uncomplicated lower urinary tract infections (UTIs)

👉🏽ti.ubc.ca/letter135

#MedEd #FOAMed #UTIs #BetterPrescribing
2/6 Use symptoms, not tests to diagnose UTIs:

Uncomplicated lower UTI can be diagnosed with > 90% probability if pt has 2 or more of dysuria, urgency, and frequency, and no vaginal discharge.

This is less reliably predicted for older women.

👉🏽ti.ubc.ca/letter135

#MedEd
3/6 No need to culture:

✅Fewer than 2% of urine cultures meaningfully impact choice of treatment or need for follow-up
✅Most guidelines recommend against culture for
symptomatic uncomplicated #UTIs

👉🏽ti.ubc.ca/letter135

#MedEd #BetterPrescribing #BetterHealth
Read 7 tweets

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