When to stop or change medications due to side effects?

When to Stop or Change Medications Due to Side Effects

Medications should be discontinued if a patient does not achieve the expected therapeutic response after an adequate trial period or if side effects significantly impact quality of life, with specific timeframes varying by medication class.

General Principles for Managing Medication Side Effects

When to Stop Medications

• Stop medications if the patient has not achieved the expected therapeutic response after an adequate trial period, with specific timeframes varying by medication class 1
• Discontinue medications when side effects significantly impact quality of life or when the burden of side effects outweighs the benefits 1
• Consider stopping medications when they are ineffective or expose patients to a higher risk of side effects, particularly when glycemic goals have changed due to development of comorbidities or aging 1

When to Change Medications

• If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one medication, consider dose modification or switching to a different medication within the same class or to a different class 1
• Switch patients to an alternative medication when they experience specific side effects associated with their current medication (e.g., switching from ACE inhibitors to ARBs when patients develop cough) 2
• Consider medication changes when there are compelling contraindications to the current therapy (e.g., gout with thiazide diuretics, asthma with beta-blockers) 1

Medication-Specific Discontinuation Criteria

Weight Management Medications

• For naltrexone ER/bupropion ER: Discontinue if the patient has not lost at least 5% of baseline body weight after 12 weeks on the maintenance dose 1
• For phentermine/topiramate ER: Discontinue if the patient has not lost at least 3% of body weight after 12 weeks on the recommended dose, or if the patient has not lost at least 5% after 12 additional weeks on the maximum dose 1
• For liraglutide 3.0 mg: Discontinue if the patient has not lost at least 4% of body weight 16 weeks after initiation 1

Cardiovascular Medications

• For antihypertensive medications, consider switching if the patient experiences significant side effects such as hypotension, dizziness, or syncope 1
• When switching from ACE inhibitors (like ramipril) to ARBs (like telmisartan), do so when patients experience side effects like dry cough with ACE inhibitors 2
• Use caution when prescribing anti-muscarinics or β3-adrenoceptor agonists in frail patients, as they may have a lower therapeutic index and a higher adverse event profile 1

Special Considerations for Specific Populations

Elderly Patients

• Use caution in prescribing medications to frail elderly patients, defined as those with mobility deficits, weight loss, and weakness without medical cause 1
• In older adults with multimorbidity, consider nonpharmacological therapies such as physical therapy or lifestyle modification as alternatives to medication to limit side effects 1
• Monitor elderly patients closely for adverse effects as they may have altered pharmacokinetics and increased sensitivity to medications 1

Pregnant Patients

• Discontinue medications that act on the renin-angiotensin system (ACE inhibitors, ARBs) as soon as pregnancy is detected due to risk of fetal abnormalities 3, 4
• When pregnancy is detected, switch to safer alternatives for blood pressure control after consulting with specialists 3, 4

Approach to Medication Side Effect Management

Monitoring and Assessment

• Regularly review medication response at appropriate intervals, including impact on efficacy and safety 1
• Assess the burden of side effects early in treatment (as early as 4 days post-treatment for some medications), as this can predict poorer treatment outcomes 5
• Document the reasons for medication changes or discontinuation to inform future treatment decisions 1

Strategies for Medication Changes

• When discontinuing medications, develop a detailed plan for safe discontinuation, especially for cardiovascular or central nervous system medications that need to be tapered 1
• Stop medications one at a time when discontinuing multiple medications to better assess the impact of each change 1
• Consider a time-limited withdrawal to clarify whether the medication was needed in the first place if there is uncertainty about discontinuing a medication 1

Common Pitfalls to Avoid

• Avoid the "prescribing cascade" where drug side effects are misidentified as a new medical condition leading to additional prescriptions 1
• Don't assume that informing patients about potential side effects will increase their incidence - studies show this is not the case 6
• Avoid making unnecessary changes to drug regimens prescribed by other healthcare providers when medically appropriate 7
• Don't discontinue medications abruptly, particularly those that act on the cardiovascular or central nervous system, as this can lead to adverse drug withdrawal events 1

By following these guidelines, clinicians can make informed decisions about when to stop or change medications due to side effects, balancing the benefits of treatment with the potential harms of adverse events.