Evaluation of Tricyclic Antidepressant Deprescribing in the Treatment of Diabetic Peripheral Neuropathy within Federally Qualified Health Centers

Chelsea Herrarte; Moises Martinez; Jasmine D Gonzalvo; Brock T Davis; Lynn M Thoma; Noll L Campbell

doi:10.1016/j.japh.2024.102113

Evaluation of Tricyclic Antidepressant Deprescribing in the Treatment of Diabetic Peripheral Neuropathy within Federally Qualified Health Centers

J Am Pharm Assoc (2003). 2024 May 3:102113. doi: 10.1016/j.japh.2024.102113. Online ahead of print.

Authors

Chelsea Herrarte¹, Moises Martinez², Jasmine D Gonzalvo³, Brock T Davis⁴, Lynn M Thoma⁵, Noll L Campbell⁶

Affiliations

¹ PGY-2 Ambulatory Care Pharmacy Resident, CommUnityCare Health Centers, Austin, TX; at time of study: PGY-1 Community-Based Pharmacy Resident, HealthLinc/Purdue University, Mishawaka, IN.
² Health Equity and Academic Administrative Fellow, Eskenazi/Purdue University, Indianapolis, IN.
³ Clinical Professor at Purdue University College of Pharmacy, West Lafayette, IN.
⁴ PGY-1 Community Pharmacy Residency Program Director, HealthLinc/Purdue University College of Pharmacy; Director of Clinical Pharmacy Services, HealthLinc, Mishawaka, IN; at time of study: Clinical Pharmacist Lead, HealthLinc, Mishawaka, IN. Electronic address: bdavis@healthlincchc.org.
⁵ Senior Consultant, Visante, Valparaiso, IN; at time of study: PGY-1 Community Pharmacy Residency Program Director, HealthLinc/Purdue University College of Pharmacy; Director of Pharmacy, Valparaiso, IN.
⁶ Associate Professor of Pharmacy Practice at Purdue University College of Pharmacy, West Lafayette, IN.

PMID: 38705467
DOI: 10.1016/j.japh.2024.102113

Abstract

Background: Tricyclic antidepressants (TCAs) are a treatment option for diabetic peripheral neuropathy (DPN). Existing evidence demonstrates the prolonged use of TCA therapy increases the risk of cognitive decline and dementia, likely due to the anticholinergic effects of these medications. The anticholinergic activity is thought to contribute significantly to the observed increase in cognitive decline and dementia risks associated with long-term TCA use. There is little information available to describe the usage patterns of TCAs in DPN, particularly within underserved populations who receive care at Federally Qualified Health Centers (FQHCs).

Objectives: The objective of this study was to characterize: 1) prescribing patterns of TCAs as a treatment for DPN and 2) evidence of deprescribing attempts in a FQHC population.

Methods: A retrospective chart review of electronic medical record (EMR) data for patients at two different FQHCs was performed. A convenience sample of 100 adults ≥ 18 years of age was stratified into two age groups, 18-55 years, and 55+ years. All patients had a diagnosis of Type 1 or Type 2 diabetes mellitus and had been prescribed TCAs in the previous four years and had a visit with a primary care provider (PCP) in the past 12 months.

Results: The study population was comprised of 100 individuals. Seventy-four of 100 were persistent users of TCAs at the time of data collection, and the mean duration of utilization was 54.8 months. In total, 104 TCAs were prescribed across 100 individual patients. Of all 104 prescribed TCAs, 66 (63%) were prescribed at a rate that exceeded thresholds associated with a higher risk of dementia. Black older adults prescribed TCAs were more likely to exceed this dose threshold.

Conclusion: 65% of patients used TCAs with a strength, frequency, and duration that exceeded risk thresholds for dementia in an older adult population. Interventions preventing use of or deprescribing TCAs in patients with DPN should be conducted for the potential benefits of preventing or delaying cognitive impairment and promoting equitable care.

Keywords: Tricyclic antidepressants; dementia; diabetes; diabetic peripheral neuropathy.