Deprescribing Medications with Dr. Trang Nguyen Part 1

Join me with integrative pharmacist, Dr. Trang Nguyen, as we dig deep on Deprescribing, what it is and how to do it.  Anyone who is on a journey to feeling healthier and is taking medications needs a strategy to start coming off medications, which is deprescribing. 

In this episode, we’ll cover how the following medications can be prescribed and how you can approach this with your doctor and pharmacist.

How to Deprescribe Medications for High Blood pressure such as:

Lisinopril, Losartan, Amlodipine and Metoprolol

You can download my downloadable Blood Pressure Journal Here:

Blood Pressure Checklist and Log

How to Deprescribe Medications for Cholesterol Medications, including:

Statins-Atorvastatin, Simvastatin Rosuvastatin

Want to calculate your cardiovascular risk?https://www.mdcalc.com/calc/3398/ascvd-atherosclerotic-cardiovascular-disease-2013-risk-calculator-aha-acc

Dr. Trang Nguyen is a Board-Certified Geriatric Pharmacist. In 2017, she found Mimosa Health LLC. Her mission is to provide expert advice on the use of medications by older adults, promote healthy aging, and educate seniors about polypharmacy as well as medication safety. Currently, she is a consultant pharmacist for Skilled Nursing Facilities and a fellow-in-training at the Academy of Integrative Health and Medicine.

She is a radio host of “The Medicine Cabinet” show which is broadcast every other Saturday at 5:30 pm Central Time from The Vietnamese Public Radio Station in Oklahoma City. She is the author of “Medication Management for 50+” book .

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Transcript

Speaker 1: 0:54

Thank you so much for joining me for this episode of the Art Healing Podcast. I was lucky enough to be able to have Dr. Tran wy, who is a board certified geriatric pharmacist, join me to discuss Deprescribing. She had previously been on my show and we had discussed, um, um, many things in the pharmacy world and how, um, it interacts with our lives. And I felt that this topic was one that we really should go back and review, uh, what deprescribing is and how to do it for different types of medications. So Dr. Wynn is a board certified pharmacist and a geriatric pharmacist, and she's the owner of Mimosa Health. And I will put the link for Mimosa Health, the website in the show notes. Uh, her mission is to provide expert advice on using medication in older adults, promote healthy aging, and educate seniors about polypharmacy and medication safety. She is a radio host of the Medicine cabinet, which is an, a featured radio show in Oklahoma City, and she's a published author of Medication Management for 50 plus. So during this episode, Dr. Wynn and I reviewed the various types of the most commonly prescribed medications and what might be a strategy when it's time to come off those medications. Enjoy. Hello Art of podcast listeners. Thank you so much for joining me. I'm very lucky that a guest I had on recently was able to come back on so that we could discuss one topic that came up during her first episode, which is Deprescribing. So I had some questions afterwards, and definitely as a practicing physician, this comes up a lot. So thank goodness Dr. Wynn, Dr. Tran Wyn was able to join us again. And in this episode we're gonna talk about Deprescribing, we'll talk about what it is, and we're gonna cover the top cla top prescriptions and her recommendations as far as what it would look like to start to come off of a medication if it's no longer needed. Dr. Wynn, thank you so much for joining me, for joining

Speaker 2: 3:26

Me. Thank you for having me. I am very honored to be with you again with the audience, to share, um, my knowledge to you and everyone about deprescribing.

Speaker 1: 3:40

Thank you so much. If you don't remind mind, if you could remind the listeners some of your background, um, and particularly why Deprescribing is so important to you, to you.

Speaker 2: 3:54

Um, I feel like we, um, in this healthcare system, we are taking so many medications and, um, and we taken those for a long time. We have seen so many, uh, specialist and, um, sometime they didn't talk to each other. Um, I feel it is necessary to de-prescribe medications that, um, might not be necess, uh, might not be needed anymore. So medication that were good then might not be the best choice now. And, um, especially in older adults, um, they can cause more harm than good. So optimizing medication by deprescribing is very important to manage chronic conditions, uh, avoid eye effects and also improve outcomes.

Speaker 1: 4:50

Thank you so much. So, um, and my next question you did answer, which is, when do we know it's time for a medication to stop and the practice of medicine? And, you know, especially in modern American medicine, many of our prescriptions are, are chronic. We don't intend to stop them, but we're embracing lifestyle medicine. You're working on becoming certified in lifestyle medicine. I'm training in functional medicine. And when we start looking at root causes and finding out that actually we can resolve diseases that we had previously, 10, 20 years ago, it said there was no, uh, cure. It turns out there is. Um, so when it's, so, it's, it's good for us to discuss that at some point we need to, you know, stop something, but it's, we have to be very careful. So, um, the first class of medications, so, um, for the listeners, um, for pharmacists and for physicians, we think about pres prescriptions differently, um, than for patients. So as we're describing these, I'll do the best I can to try to, to make that translation. Um, cuz she and I will be somewhat pharmaceutical. Um, so the first one I wanted to ask Dr. Wn about were medications to lower blood pressure or antihypertensive. So she and I will go a little bit deeper because they're different types of antihypertensive, but from my research, the most commonly prescribed medications we take when you have high blood pressure are lisinopril, losartan, amlodipine and metoprolol. So if someone has high blood pressure, that's better, they've, let's say just as an example, they've lost weight, they're eating a healthy diet, they hardly eat anything processed. So their sodium take is much better now. Um, they're getting out, getting some healthy movement and they feel 10 years younger now than they did years ago. So, Dr. We, if this person's taking medications to lower blood pressure, what's the approach when it's time to come off of those?

Speaker 2: 7:11

I mean, when the patient's ready, when they come to you and visit you for annual checkup, they say, I'm, I feel like I I'm taking too many medications. That's the, uh, sign and or signal for you to look deeper into the medication regimen. I have seen patients on five different, uh, classes of, uh, high blood pressure medications and I feel like that is too much, especially for an older adult that stay in bed every single day. They're not going out, they're not moving anywhere. Putting them on five different, uh, high blood pressure medication is, I feel like is way too many. So the first thing I will look into is the duplication of therapy, um, because sometimes specialists and primary care physicians will prescribe two different medications until that pharmacist look into that. It's a duplication of therapy. I'll give you some example. Uh, so you list out ceil or low sortin, they, they two medication in two different classes, but technically they work the same way. Um, so that's to me is a duplication of therapy and I have seen that in, uh, the pharmacy or a, uh, two medications from calcium channel blockers, uh, like amlodipine and athe. I have seen patient on both of them and, uh, from two different prescriber or even from the same prescriber. Um, so that's a duplication of therapy that you can eliminate. You can de-prescribe one of them, or you, I have seen patient on two beta blockers, um, and or taking, uh, beta blockers in clonidine. So, um, they're two different classes, but the way it work, it, it, um, it have similar effects. So that's the, uh, we call it low hanging fruit. We can get rid of duplication of therapy. That's the first thing that we should look into before we do anything else. And then we look into, um, you talk about lifestyle changes, is the patient want to do it or not? A lot of patients don't want to make any changes and those, uh, the people that very hard to get them off medication. Um, so they rather take five pills for blood pressure than to change the diet or exercise or, uh, do anything else that lower their blood pressure. Um, so that you have to constantly, uh, we caught motivational interview, we have to see where they at. So if they're not ready, we're not pushing them to get off medication. Um, but when they're ready, you will start, he, um, help them do the blood pressure log. So they will write down, um, what time of the day they measure the blood pressure. And then you can see the parent that in the afternoon, uh, that the blood pressure is high or in the morning or at night. Um, if the patient take too many medication at night, then in the morning that will help very low blood pressure. Or, uh, if they take too many medication in the morning, then usually in the afternoon, the med medication we off and they have low, uh, they have high blood pressure in the afternoon. And so you have to see the parent and see if we, if we can move, uh, the schedule around between blood pressure medications, uh, see if, help them under control. And then from that, um, slowly lower the dose. Uh, because medication does, uh, some medications like better blockers, uh, quantity may have some rebound, uh, hypertension. That mean if you get them up too quickly, they will, the blood sugar will go up and then that will scare the patient and they'll say, no, I'm not, I I will never take up that medication because I did it before and it's not successful. So we have to be careful with blood pressure medication that, um, that, uh, don't scare the patient when they get up because they might have side effects if they get up too quickly. So we have, and then we also look into liver, the kidney, um, uh, if they have diabetes, uh, we follow the guidelines. So we have guidelines, uh, with other disease, um, that they have that they might need certain medication for long term they cannot get off, but we can always lower the dose, um, when the blood pressure under control. So there's different way to, to approach the this, um, deprescribing, um, issue. So it it's just up to you, uh, as physician and the patient and see what they want to do.

Speaker 1: 12:27

So it sounds like from your advice, the one thing that, um, a listener if they're being treated for high blood pressure or the few things they'll need to get started with is possibly understanding what they're taking, cuz it's possible they could be taking different types of blood pressure medications. Then from there, when they work with their doctor, understanding as they're coming off that we might see the, the rebound hypertension. And so being prepared for that. So they need to have a working blood pressure cuff and then a way to track their blood pressure. And, and that would be maybe the best place to start. For instance, if you're listening and you have a doctor's visit coming up, then that's a way you can prepare before you get to the doctor's office is making sure you've got your cuff ready, you're ready to track, and then knowing, um, which medicines you take to lower your blood pressure. So, great, thank you so much. Thank you so much. Then the next, the next class of medications that are commonly prescribed, um, are to lower cholesterol. So high cholesterol has several names you'll hear clinically and you hear in conversation. Um, will use a, use the term hyperlipidemia, mixed hyperlipidemia, high cholesterol, dyslipidemia, all of that kind of, you know, rounds around to your, one of your cholesterols that we think is dangerous, that can cause damage to your blood vessels is too high. So we have the medications that are commonly known as the statins that are prescribed to lower. So the common statins are the generic name, atorvastatin or systa. Um, and there are several of these, um, on the market. But, uh, Dr. Wynn, when it comes to deprescribing statins, what are your recommendations?

Speaker 2: 14:28

<laugh>? I usually teach the patient how to read the cholesterol panel, uh, because, um, most of the time physician will call them and say, Hey, your total cholesterol way too high is over 200. You have to be un statin forever. Um, i, I teach them how to read the, um, that number because if you have, I have seen patient in nursing home, one is both them do have total cholesterol over 200, but one of them has to be on cholesterol medication and one of them, uh, is not, they, don't, they, they just, they doesn't have to be on cholesterol medication. So why is that? So total cholesterol is this a formula to calculate total cholesterol. So you have to look at the hdl, ldl and then they tri cholesterol. So if you look at those numbers, they, they varies, uh, even though your total cholesterol number is the same for two patients, for example, but the individual, so if they have high, uh, hdl, good cholesterol and, but they have low, uh, LDL and low triglyceride, when you add it up with that formula, you can google that formula, it come out with over 200 because your HDL is 150, which is not very common. But I have seen some older adults, they're very healthy, they have very high cholesterol, uh, high hdl. So that make the number looks really, the total cholesterol number looks really bad. But in fact they, they have low risk because they have very high hdl, but they have low, very low LDL and low tri cholesterol. So that person not supposed to take statin drug. And then you look at another case, um, a common case will be most patient I have seen, they have low hdl, which is slow good cholesterol, but they have very high ldl or high or both, uh, high tri cholesterol. So this type will be on cholesterol medications or medications that treat, um, LDL or treat high LDL or treat high tricho. So that is the, the right way to put patient on, uh, cholesterol medications. So when you look at that, you will, uh, reevaluate and say, should I be on co cho or not? That is how I evaluate and recommend for deprescribing. So we have to, uh, find the right candidate to be on, uh, CHO medication in general. And then I'll ask for the risk, uh, the benefit, uh, side effects or drug interaction. So, um, so if after I evaluate all of that, I will make recommendation to de-prescribe. So if they on it because they have a stroke or because of the guidelines, uh, some guidelines recommendation on cholesterol to prevent stroke, um, so that, that we can evaluate on that, even though their cholesterol number looks really good, but that's for prevention. You can always put the patient on low dose. Um, I know the guidelines put patient on very high dose of cholesterol medications and I, I feel like it's not appropriate for everyone. So, um, I know guidelines, I feel like guideline is just a guy, it's not a bible. So we have to individualize our plan for each patient. And of course we always mention the lifestyle, so which, uh, uh, patient that can do it, which patient cannot. So we have, look, we have to look into it with patient that cannot cook, cannot, uh, um, take care of themselves. Sometimes they don't have a choice about the food they eat. So we, we, uh, be careful when we take up cholesterol medications or with patient that they motivate to change. Um, then we can, uh, keep, uh, watching them, uh, and then encourage, encourage them to, um, you know, do lab work every year so we can follow up with them. Um, but most patient, I I look into the cholesterol in cholesterol panel and then I will explain to them what each numbers mean and, um, I have patient call me up and, and freak out because their physicians want them to be on collateral medication. And so I explained to them why they want them to be on it and why they should not be on it. So that's a way to de-prescribe, uh, cholesterol medication. So mostly lifestyle changes and then understand what each cholesterol number means, and then we can, um, help patient to get on a cholesterol medication or get off a cholesterol medication.

Speaker 1: 19:50

So, um, if you've got a visit coming up, it might help if you've got the information of, um, what your last cholesterol reading was, that could be helpful. And then being prepared to just have some awareness about how you're living. So having some awareness of your diet, having some awareness of your activity level. Definitely having some awareness of like if there's some goals that you wanna meet. Um, whenever I'm working with patients and we come to this discussion of maybe it's time to de-prescribe a statin, typically what we do, and depending on the setting, cause Dr we mentioned that there are gonna be some higher risk individuals where it, it has to be a different conversation. We have to protect your blood vessels and the brain or around the heart. Um, but typically I would recommend that we could, um, you know, make sure we know where you start, go ahead and pause the medication and then maybe check your cholesterol after you've been off of it and make sure that you indeed did okay that you did okay with the lifestyle. So thanks Dr. Wyn. That's a great explanation. Thank you so much for joining me for this episode of the Art Healing Podcast. I wanted to close things off this episode to remind you that, um, I've got some new projects that are available. One of those is a course in mindfulness, uh, topic that's near and dear to me. That is, um, something that I have been using in my own personal practice of healing and growth and I'm so excited to share with the world. So if you're interested, click your show notes to find out more. And then I am working on my book, the Heart of Being, and um, I am looking for readers who wanna give me some input. So if you would be interested in receiving, um, a, uh, small bit of the book, um, I'll put a link below to send me a message. Thanks so much.