Deprescribing medications that may increase the risk of hepatic encephalopathy: A qualitative study of patients with cirrhosis and their doctors

Abstract

Background and AimsMultiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis.MethodsWe conducted, transcribed, and analyzed semi‐structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing.ResultsMajor provider‐specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient‐specific barriers included knowledge gaps regarding the cirrhosis‐specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider’s opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach.ConclusionGiven knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy‐based deprescribing outreach and patient‐facing education on risks are warranted.Key SummarySummarize the established knowledge on this subjectHepatic encephalopathy (HE) is a morbid complication of cirrhosis.The risk of HE may be increased by psychoactive medications and proton pump inhibitors.Deprescribing is felt to be a promising approach to HE prevention.What are the significant and/or new findings of this study?Patients are unaware of how their medications influence the risk of HE.Patients are willing to follow physician recommendations regarding deprescribing but are afraid of worsening symptoms.Physicians do not feel comfortable deprescribing opioids or benzodiazepines.Physicians do not feel responsible or equipped with the resources for deprescribing.