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Deprescribing clonazepam in primary care older patients: a feasibility study

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Abstract

Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.

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References

  1. Miranda GMD, Mendes ACG, Silva ALA. O envelhecimento populacional brasileiro: desafios e consequências sociais atuais e futuras. Rev Bras Geriatr Gerontol. 2016;19(3):507–19. https://doi.org/10.1590/1809-98232016019.150140.

    Article  Google Scholar 

  2. Oliveira AS. Transição demográfica, transição epidemiológica e envelhecimento populacional no Brasil. Hygeia Rev Bras Geogr Méd Saúde. 2019;15(32):69–79. https://doi.org/10.14393/Hygeia153248614.

    Article  Google Scholar 

  3. Malta DC, Stopa SR, Szwarcwald CL, et al. A vigilância e o monitoramento das principais doenças crônicas não transmissíveis no Brasil – pesquisa nacional de saúde, 2013. Rev Bras Epidemiol. 2015;18(2):3–16. https://doi.org/10.1590/1980-5497201500060002.

    Article  PubMed  Google Scholar 

  4. Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde [página da internet]. O que é Atenção Primária à Saúde? Brasília, DF. https://aps.saude.gov.br/smp/smpoquee. Accessed from 29 Sep 2021.

  5. Baldoni AO, Chequer FMD, Ferraz ERA, et al. Elderly and drugs: risks and necessity of rational use. Braz J Pharm Sci. 2010;46(4):617–32. https://doi.org/10.1590/S1984-82502010000400003.

    Article  Google Scholar 

  6. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151(9):1825–32. https://doi.org/10.1001/archinte.1991.00400090107019.

    Article  CAS  PubMed  Google Scholar 

  7. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med. 1997;157(4):1531–6. https://doi.org/10.1001/archinte.1997.00440350031003.

    Article  CAS  PubMed  Google Scholar 

  8. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.

    Article  PubMed  Google Scholar 

  9. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Societ updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31. https://doi.org/10.1111/j.532-5415.2012.03923.x.

    Article  Google Scholar 

  10. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46. https://doi.org/10.1111/jgs.13702.

    Article  Google Scholar 

  11. American Geriatrics Society 2019 Beers Criteria® Update, Expert Panel. 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 

  12. Oliveira MG, Amorim WW, Oliveira CRB, et al. Consenso Brasileiro de medicamentos potencialmente inapropriados para idosos. Geriatr Gerontol Aging. 2016;10(4):168–81. https://doi.org/10.5327/Z2447-211520161600054.

    Article  Google Scholar 

  13. Control NIB. Report of the international narcotics control board for 2017. 2018. https://www.incb.org/documents/Publications/AnnualReports/AR2017/Annual_Report/E_2017_AR_ebook.pdf . Accessed from 31 Mar 2020.

  14. Brasil. Ministério da Saúde. Secretaria de ciência, tecnologia e insumos estratégicos. Departamento de Assistência farmacêutica e insumos estratégicos. uso de medicamentos e medicalização da vida: recomendações e estratégias. [recurso eletrônico]/Ministério da Saúde secretaria de ciência tecnologia e insumos estratégicos departamento de assistência farmacêutica e insumos estratégicos – Brasília: Ministério da Saúde 2018. p. 33 http://bvsms.saude.gov.br/bvs/publicacoes/medicamentos_medicalizacao_recomendacoes_estrategia_1ed.pdf Accessed from 31 Mar 2020.

  15. Xing D, Ma XL, Ma JX, et al. Association between use of benzodiazepines and risk of fractures: a meta-analysis. Osteoporos Int. 2014;25:105–20. https://doi.org/10.1007/s00198-013-2446-y.

    Article  CAS  PubMed  Google Scholar 

  16. Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in community. Age Ageing. 2015;44(1):90–6. https://doi.org/10.1093/ageing/afu141.

    Article  PubMed  Google Scholar 

  17. Naloto DCC, Lopes FC, Barberato-Filho SL, et al. Prescrição de benzodiazepínicos para adultos e idosos de um ambulatório de saúde mental. Ciênc Saúde Colet. 2016;21(4):1267–76. https://doi.org/10.1590/1413-81232015214.10292015.

    Article  Google Scholar 

  18. Billioti de Gage S, Bégaud B, Bazin F, et al. Benzodiazepine use and risk of dementia: prospective. BMJ. 2012;345:e6231. https://doi.org/10.1136/bmj.e6231.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Rosenberg K. Benzodiazepine use increases Alzheimer’s risk. AJN. 2015;115(1):56.

    Google Scholar 

  20. Medronho RA, Bloch KV, Luiz RR, et al. Epidemiologia. 2nd ed. São Paulo: Atheneu; 2009. ISBN: 978-85-7379-999-6

    Google Scholar 

  21. Instituto Brasileiro de Geografia Estatítica. Panorama cidades: divinópolis. 2020. https://cidades.ibge.gov.br/brasil/mg/divinopolis. Accessed from 04 Apr 2020.

  22. Instituto Brasileiro de Geografia Estatítica. Panorama cidades: itaúna. 2020. https://cidades.ibge.gov.br/brasil/mg/itauna/panorama. Accessed from 04 Apr 2020.

  23. Smith WT, Londborg PD, Glaudin V, et al. Short-term augmentation of fluoxetine with clonazepam in the treatment of depression: a double-blind study. Am J Psychiatry. 1998;155(10):1339–45. https://doi.org/10.1176/ajp.155.10.1339.

    Article  CAS  PubMed  Google Scholar 

  24. Grushka M, Epstein J, Mott A. An open-label, dose escalation pilot study of the effect of clonazepam in burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86(5):557–61. https://doi.org/10.1016/s1079-2104(98)90345-6.

    Article  CAS  PubMed  Google Scholar 

  25. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do miniexame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777–81.

    Article  PubMed  Google Scholar 

  26. Farrell B, Pottie K, Rojas-Fernandez CH, Bjerre LM, Thompson W, Welch V. Methodology for developing deprescribing guidelines: using evidence and GRADE to guide recommendations for deprescribing. PLoS ONE. 2016;11(8):1–12.

    Article  Google Scholar 

  27. Baldoni AO, Zadra PF, Vilar LG, et al. Elaboração e validação do protocolo de desprescrição do clonazepam em idosos. RBMFC. 2020;15(42):1–14. https://doi.org/10.5712/rbmfc15(42)2105.

    Article  Google Scholar 

  28. Bertolazi AN, Fagondes SC, Hoff LS, et al. Validation of the Brazilian Portuguese version of the Pittsburgh sleep quality index. Sleep Med. 2011;12(1):70–5. https://doi.org/10.1016/j.sleep.2010.04.020.

    Article  PubMed  Google Scholar 

  29. Silveira MB, Saldanha RP, Leite JCC, et al. Construction and validation of content of one instrument to assess falls in the elderly. Einstein (Sao Paulo). 2018;16(2):eAO4154. https://doi.org/10.1590/S1679-45082018AO4154.

    Article  Google Scholar 

  30. Fleck MPA, Louzada S, Xavier M, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref.” Rev Saúde Públ. 2000;34(2):178–83. https://doi.org/10.1590/S0034-89102000000200012.

    Article  CAS  Google Scholar 

  31. Bichara IM, Vilar L, Zadra P, et al. Educação e medidas não farmacológicas que promovam a qualidade do sono em idosos. Rev Bras Ext Univ. 2019;10(1):35–42. https://doi.org/10.24317/2358-0399.2019v10i1.8214.

    Article  Google Scholar 

  32. Tyrer P, Murphy S, Riley P. The benzodiazepine withdrawal symptom questionnaire. J Affect Disord. 1990;19:53–61. https://doi.org/10.1016/0165-0327(90)90009-W.

    Article  CAS  PubMed  Google Scholar 

  33. Durbin K. Clonazepam: overview. In: Drugs.com [Internet]. Cerner Multum, Inc. 2018. https://www.drugs.com/clonazepam.htm. Accessed from 06 Apr 2020.

  34. Bourgeois J, Elseviers MM, Van Bortel L, et al. Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study. Eur J Clin Pharmacol. 2014;70(10):1251–60. https://doi.org/10.1007/s00228-014-1725-7.

    Article  CAS  PubMed  Google Scholar 

  35. Vicens C, Sempere E, Bejarano F, et al. Efficacy of two interventions on the discontinuation of benzodiazepines in long-term users: 36-month follow-up of a cluster randomised trial in primary care. Br J Gen Pract. 2016;66(643): e8591. https://doi.org/10.3399/bjgp16X683485.

    Article  Google Scholar 

  36. Garzón C, Guerrero JM, Aramburu O, et al. Effecf of melatonin administration on sleep, behavioral disorders and hypnotic drug discontinuation in the elderly: a randomized, double-blind, placebo-controlled study. Aging Clin Exp Res. 2009;21(1):38–42. https://doi.org/10.1007/BF03324897.

    Article  PubMed  Google Scholar 

  37. Votaw VR, Geyer R, Rieselbach MM, et al. The epidemiology of benzodiazepine misuse: a systematic review. Drug Alcohol Depend. 2019;200:95–114. https://doi.org/10.1016/j.drugalcdep.2019.02.033.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Coutinho ESFS, Dutra S. Uso de medicamentos como fator de risco para fratura grave decorrente de queda em idosos. Cad Saude Publ. 2002;18(5):1359–66. https://doi.org/10.1590/S0102-311X2002000500029.

    Article  Google Scholar 

  39. Marron L, Segurado R, Kenny RA, et al. The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study. QJM. 2020;113(1):31–6. https://doi.org/10.1093/qjmed/hcz217.

    Article  CAS  PubMed  Google Scholar 

  40. McDonald EM, Caslangen J. Benzodiazepine use and falls in older adults: is it worth the risk? Res Gerontol Nurs. 2019;12(5):214–6. https://doi.org/10.3928/19404921-20190813-01.

    Article  PubMed  Google Scholar 

  41. Lenander C, Bondesson A, Viberg N, et al. Effects of medication reviews on use of potentially inappropriate medications in elderly patients; A cross-sectional study in Swedish primary care. BMC Health Serv Res. 2018;18(1):1–9. https://doi.org/10.1186/s12913-018-3425-y.

    Article  Google Scholar 

  42. Van Strien AM, Koek HL, Van Marum RJ, et al. Psychotropic medications, including short acting benzodiazepines, strongly increase the frequency of falls in elderly. Maturitas. 2013;74(4):357–62. https://doi.org/10.1016/j.maturitas.2013.01.004.

    Article  CAS  PubMed  Google Scholar 

  43. Brunton L, Hilal-Dandan R, Knollmann B. As bases farmacológicas da terapêutica de goodman e Gilman. 13ª ed. Porto Alegre: AMGH Editora LTDA; 2018. ISBN: 8580556147

  44. Chen TT, Ko CH, Chen ST, et al. Severity of alprazolam dependence and associated features among long-term alprazolam users from psychiatric outpatient clinics in Taiwan. J Formos Med Assoc. 2015;114(11):1097–104. https://doi.org/10.1016/j.jfma.2014.04.004.

    Article  CAS  PubMed  Google Scholar 

  45. Gupta S, Garg B. A case of etizolam dependence. Indian J Pharmacol. 2014;46:655–7. https://doi.org/10.4103/0253-7613.144943.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Rickels K, Case W, Schweizer E. The drug treatment of anxiety. Stress Health. 1988;4:231–9. https://doi.org/10.1002/smi.2460040408.

    Article  Google Scholar 

  47. Longo LP, Johnson B. Addiction: part I. Benzodiazepines – side effects, abuse risck and alternatives. Am Fam Physician. 2000;61(7):2121–8.

    CAS  PubMed  Google Scholar 

  48. Curran HV, Collins R, Fletcher S, et al. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Psychol Med. 2003;33(7):1223–37. https://doi.org/10.1017/s0033291703008213.

    Article  CAS  PubMed  Google Scholar 

  49. Santos SLF, Almeida RDO, Paiva CEQ, et al. Serviço de atendimento farmacêutico ao idoso: relato de experiência de educação em saúde. Saúde (Sta Maria). 2016;42(2):225–31. https://doi.org/10.5902/2236583421522.

    Article  Google Scholar 

  50. Salonoja M, Salminen M, Aarnio P, et al. One-time counselling decreases the use of benzodiazepines and related drugs among community-dwelling older persons. Age Ageing. 2010;39(3):313–9. https://doi.org/10.1093/ageing/afp255.

    Article  PubMed  Google Scholar 

  51. Marques LAM, Nogueira VAS, Tiengo A. Avaliação do uso de benzodiazepínicos por clientes de uma drogaria privada. Rev Univ Vale do Rio Verde. 2013;11(1):234. https://doi.org/10.5892/813.

    Article  Google Scholar 

  52. Souza ARL, Opaleye ES, Noto AR. Contextos e padrões do uso indevido de benzodiazepínicos entre mulheres. Cienc Saúde Colet. 2013;18(4):1131–40. https://doi.org/10.1590/S1413-81232013000400026.

    Article  Google Scholar 

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This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brazil (CAPES)—Finance Code 001.

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Correspondence to Luanna Gabriella Resende da Silva.

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da Silva, L.G.R., da Silva Pinto, A.W., de Queiroz, W.E. et al. Deprescribing clonazepam in primary care older patients: a feasibility study. Int J Clin Pharm 44, 489–498 (2022). https://doi.org/10.1007/s11096-021-01371-7

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