How do you manage long-term side effects of medications?

Managing Long-Term Side Effects of Medications

The most effective approach to managing long-term side effects of medications involves regular monitoring, systematic tapering when needed, and comprehensive follow-up care that prioritizes patient safety and quality of life. 1

Systematic Monitoring and Assessment

• Regularly monitor treatment effects, clinical parameters, and side effects at follow-up appointments, checking for nonspecific symptoms that may indicate complications from medications (e.g., dry mouth, weakness, fatigue, drowsiness, reduced alertness, sleep disturbances, motor disorders, tremors, falls, gastrointestinal issues, skin reactions, mood changes) 1
• Consider increasing the frequency of follow-up visits following treatment changes or when side effects are reported 1
• For medications with known risks, implement specific monitoring protocols (e.g., complete blood count for medications with bone marrow suppression risk, liver function tests for hepatotoxic medications) 1, 2
• Use laboratory tests and clinical investigations to detect adverse effects before they manifest as clinically significant adverse reactions 3

Safe Medication Tapering

• When discontinuing medications associated with dependence or withdrawal (e.g., opioids, benzodiazepines, Z-drugs, gabapentinoids, antidepressants), implement careful tapering rather than abrupt cessation 1
• Approximately 50% of patients prescribed opioids for chronic non-cancer pain, gabapentinoids, benzodiazepines, or Z-drugs have been treated continuously for at least 12 months, often contrary to clinical guidelines 1
• Tapering should be individualized, with slower tapers generally more successful and better tolerated than rapid discontinuation 1
• Provide patients with self-management support during medication tapering, including specific arrangements about follow-up to review decisions made 1

Medication-Specific Considerations

Opioids

• Abrupt reduction or discontinuation of opioids has been associated with serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide 1
• Implement patient-centered, integrated, comprehensive tapering models employing a biopsychosocial perspective 1

Psychotropic Medications

• For benzodiazepines and Z-drugs, employ the lowest effective maintenance dosage and taper when conditions allow 1
• Cognitive behavioral therapy for insomnia (CBT-I) can facilitate medication tapering and discontinuation 1
• Monitor for withdrawal symptoms when tapering antidepressants, which may require very gradual dose reduction 1

Polypharmacy Management

• Review and update medication plans regularly to recognize and record changes in needs 1
• Prioritize discontinuation of medications with unfavorable risk-benefit profiles, particularly in older adults 2
• Antithrombotic and antidiabetic medications, diuretics, and nonsteroidal anti-inflammatory drugs cause most preventable hospital admissions due to adverse drug events 2

Patient Education and Communication

• Provide clear information about potential side effects without creating unnecessary anxiety, as studies show that informing patients about medication side effects generally does not increase their occurrence or negatively impact compliance 4
• Ensure patient education includes treatment goals and expectations, safety concerns, potential side effects and drug interactions, other treatment modalities, potential for dosage escalation, and rebound effects 1
• Explain to patients and their family members how to identify and report medication-related safety incidents 1
• Involve patients in shared decision-making regarding medication changes, particularly for long-term therapy 2

Special Populations

Older Adults

• Adverse drug events occur in 15% or more of older patients and are potentially preventable up to 50% of the time 2
• Use screening tools such as Beers, STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions), and START (Screening Tool to Alert Doctors to Right Treatment) criteria to identify medications causing adverse events 2
• Strategies to reduce adverse events include discontinuing unnecessary medications, prescribing new medications sparingly, reducing the number of prescribers, and frequently reconciling medications 2

Documentation and Follow-Up

• Document all side effects, interventions, and outcomes to guide future treatment decisions 1
• Monitor ongoing treatment including demonstrations of medication administration (e.g., inhalers) and effective forms of self-monitoring 1
• Consider continuing to offer information and support even if patients have declined this previously, recognizing that conditions can be changeable or progressive 1

Common Pitfalls to Avoid

• Failing to recognize that even grade 1 (mild) adverse events, if chronic, can substantially affect quality of life 1
• Inadequate monitoring after hospital discharge, when newly introduced medications may not have reached steady state 1
• Overlooking the potential for drug interactions when adding new medications to an existing regimen 1, 5
• Underestimating the importance of systematic medication reconciliation, particularly during care transitions 2