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COLLABORATIVE DEPRESCRIBING IN PALLIATIVE CARE: A MULTIDISCIPLINARY APPROACH TO MEDICATION OPTIMISATION

European Statement

Clinical Pharmacy Services

Author(s)

A Wagner, D Weixler, C Waidinger, M Josl

Why was it done?

A pharmacist, integrated in the palliative care team, reviewed preselected patients with advanced disease to identify potentially inappropriate medications (PIMs). When appropriate, a team of physicians deprescribed PIMs in accordance to patient preferences, clinical status and rationale. The initiative aimed to identify PIMs, reduce pill burden and align pharmacotherapy with individual treatment goals.

What was done?

Up to 96% of geriatric oncological palliative care patients experience polypharmacy (>5 medications) (1), with up to 70% receiving at least one PIM referring to Lindsay J et al. (2).
Deprescribing is considered appropriate in certain clinical situations, including for example:
– presence of polypharmacy
– patient’s wish
– shift in treatment strategy or goals
– limited life expectancy
– when potential harm outweighs benefits

How was it done?

– Weekly interdisciplinary meetings
– Eligible patients were identified by the palliative care physicians based on prognosis, symptom burden, medication profile (polypharmacy), and patient wishes
– Pharmacist reviewed medications using medical records, identified potential deprescribing opportunities and provided tailored deprescribing recommendations (what and how to deprescribe)
– Recommendations were collaboratively discussed and documented
– If deprescribing was implemented, follow-up was conducted at the next patient visit and was subsequently monitored during regular consultations

What has been achieved?

During observation period, three patients (all male, median age 80) received a structure deprescribing review. A total of 59 drugs were targeted, 20 PIMs have been identified.
Commonly deprescribed medication groups were gastroprotective drugs (A02B), urological agents (G04B, G04C) antihypertensives (C02A, C09A, C08C, C03C) and vascular or miscellaneous agents (C05B, N06DX, N07A). Typical reason for discontinuation included stable blood pressure, presence of indwelling urinary catheter, patient-driven deprescribing request, therapeutic futility.
Other drug classes such as psychotropics (N06A, N04B), cognitive enhancers (N06D) and bone-metabolism agents (M05B, A12A) were occasionally discontinued when adverse drug effects outweighed potential benefit or did not align with palliative goals (long-term preventive therapy). Main drivers for deprescribing were patient wishes to reduce pill burden, complex symptom management and avoidance of adverse effects.

What next?

The initiative demonstrated feasibility, safety, and transferability of pharmacist-supported deprescribing as part of a multidisciplinary team. Next steps could include the development of interprofessional training sessions and expansion to other clinical settings.

LOCAL FORMULARY OF PALLIATIVE CARE IN THE ADULT PATIENT: A MULTIDISCIPLINARY APPROACH TO SYMPTOM RELIEF AND CONTINUITY OF CARE

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European Statement

Clinical Pharmacy Services

Author(s)

Francesca Baldi (1), Irene Bosoni (1), Sofia Filippini (1), Annamaria Valcavi (1), Gradellini Federica (1)
Alessia Rondini (3), Monica Salsi (3), Silvia Tanzi (2), Sara Alquati (2), Corrado Bacchi (3)
1. Pharmacy Department, Azienda USL-IRCCS, Reggio Emilia, Italy.
2. Palliative Care Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.
3. Hospice Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.

Why was it done?

Palliative care (PC) involves a network of hospitals and healthcare facilities supported by teams of nurses, specialists, general practitioners, and pharmacists. Off-label drugs are used to manage symptoms that do not respond to standard therapies, as permitted by law when no alternatives are available and under medical supervision. The National Health Service reimburses these drugs, but their use requires authorization based on proven safety and efficacy, potentially limiting patient access. Identifying essential drugs for symptom management is crucial to ensure a good quality of life.

What was done?

The AUSL of Reggio Emilia – IRCCS developed the “Local formulary of Palliative Care in Adult Patients” to support pharmacological management in PC. This formulary outlines key symptoms and provides evidence-based pharmacological options derived from scientific literature and clinical guidelines.

How was it done?

A multidisciplinary team of pharmacists, palliative care specialists, and nurses developed the formulary, defining essential treatments for palliative care across various local care settings. First published in 2019 and updated in 2022, the formulary specifies for each drug the indication, dosage, main side effects, and route of administration. Besides, it clarifies whether the use is in-label or off-label, based on the latest studies, accredited guidelines, and Italian legislation on off-label drug use. Off-label treatments are included to address multiple clinical needs when no approved therapeutic options exist, reducing empirical prescribing practices.

What has been achieved?

The formulary covers 16 symptoms, 99 drugs, and 30 active ingredients, ensuring continuity of care across the PC network. It allows PC specialists to prescribe listed medications, facilitating patient access to necessary therapies. This evidence-based system supports off-label use when approved options are unavailable, ensuring both patient safety and legal protection for healthcare providers. The tool is accessible to healthcare professionals through an electronic prescribing and administration system and in the company’s intranet section, promoting information sharing and continuity of care in hospital, community and home settings.

What next?

Clinical pharmacists play a critical role in ensuring appropriate prescribing and the proper implementation of the electronic system. Future steps include updating the formulary and expanding pharmacist training in palliative care

DEVELOPING USE GUIDELINES FOR PATIENTS AT SPECIAL SITUATIONS

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