Intervention to Manage and Prevent Overuse of Potentially Inappropriate Medications in Dialysis (IMPROVED): A...

Deprescribing, a proactive systematic approach to reducing or stopping medications, may lower adverse outcomes in older adults receiving dialysis. We evaluated the feasibility of an intervention to deprescribe potentially inappropriate medications, defined as medications whose risks often outweigh the benefits in older adults.

In this non-randomized feasibility study in Durham, NC, study personnel reviewed charts to identify potentially eligible patients (age ≥55, active potentially inappropriate medication prescription, and appropriate for deprescribing) and generated deprescribing recommendations. Clinicians at participating dialysis clinics received recommendations for each patient. When clinicians agreed, they or study staff engaged patients in shared decision-making. For deprescribing attempts, the study provided taper plans, guidance on alternatives, and adverse drug withdrawal event monitoring. Feasibility outcomes included demand, limited efficacy, acceptability, and practicality. To assess patient acceptability, eligible patients were invited to participate in semi-structured interviews.

Among 632 charts reviewed, 85 patients were potentially eligible for deprescribing. After confirming eligibility and obtaining clinician agreement, 41 of the 85 patients were approached about deprescribing; 17 (41%) agreed to attempt deprescribing. Gabapentin was the most commonly deprescribed medication (n=15; 88%). Among those who attempted deprescribing, 7 (41%) experienced symptom recurrence, but none required unplanned healthcare use. Clinician responses were mixed: five of seven reported the intervention met their approval or seemed doable, but only two reported it fit within their usual workflow. Qualitative interviews highlighted that patients generally viewed the deprescribing discussions favorably but desired clearer explanations of the deprescribing rationale.

This feasibility study demonstrates that deprescribing potentially inappropriate medications in older adults receiving hemodialysis is achievable, with good patient engagement, and no significant adverse drug withdrawal events. Clinician support was variable, with workflow integration as a key barrier. Improved workflow integration and strengthened shared decision-making processes are needed to support implementation in a future clinical trial.