Hello, everyone. My name is Roy Chang, a professor of Psychiatry at the University of Pittsburgh School of Medicine and Chief of the Comprehensive Recovery Service Line, which is part of UPMC as Western Psychiatric Hospital. Um The topic for today's CMI is titled Less. Is More Reducing the anti Colin ergic medication burden in patients receiving antipsychotic medicines. My co conspirators and presenters in the CMI are people you might have seen if you've seen the previous series, Jessica again is an associate professor at the University of Pittsburgh School of Medicine and Medical Director of the CRS ambulatory clinics and director of the Service lines Education and training program. She has another hat in which she is the medical director of the W P I C Ambulatory the Record. And this again is affiliated with UPMC Western Psychiatric Hospital. Um on a loop. You is an adjunct instructor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy and she's a clinical pharmacist at the Forbes Pharmacy here at UPMC Western Psychiatric Hospital. So welcome and I'll get started and then I'll hand off to honor who in turn will hand off to Dr Gannon and then we'll end with a few questions at the end. So um two Talk about the learning objectives of the CMI We have four um to define E P S or extra parameters, symptoms and side effects and what medicines are used to treat them, to identify the side effects that are associated with the side effect medicines. In other words, what side effects to anti Colin ergic medicines bring on their own and how do we go about reducing this burden and improve clinical outcomes and the quality of life and people receiving these anti colony medicines. And then finally, our fourth objective is to discuss what might be the predictors of all barriers to success in deep prescribing anti colony GIC medications. So the next slide, um all three of us along with Dr Brauer are copyright holders of three tools where we will point these out to you. The copyright itself has been assigned to the University of Pittsburgh and UPMC. And you know, we have at this point, no commercial interest to disclose other than that. So the basis of the CME is about seven years worth of work roughly and is reflected in three, you know, pilot projects that were done. Project one was truly the pilot we did a project to and then a project three, 2017 was the first publication and in 2021 and also in 2021 were the 2nd and 3rd publications. A lot of this will be discussed by my co presenters, but I just want to give you a sense of what has happened since we began this seven years ago. Um and this is the background on which we have updated this particular continuing medical education. So the next slide um we'll talk a little bit about why do we prescribe anti Colin ergic medications in the first place, you know, to treat clearly acute extra programmable side effects, which we often refer to in psychiatric and pharmacy practice as E P S. A lot of antipsychotic medicines which tend to be potent blockers of the dopamine receptors, otherwise known as the two receptor antagonists. They can induce CPS and this is often mitigated, sometimes completely relieved by anti colony jik medications such as Ben Strope in otherwise known as Cogent in Tri Hex fan. It'll otherwise known as arcane and diphenhydrAMINE, otherwise known as Benadryl. Sometimes these medicines are used for other types of side effects such as hyper salivation and used typically like clothes or sometimes by other antipsychotic drugs. They're also used and neurology practice for tardive dystonia as well as Parkinsonism. Alright. So the next slide will talk about what this might look like in psychiatric practice. In other words, what are the three main types of extra programmable side effects on the left is the classic triad of Parkinson Ian symptoms seen in Parkinson's disease, which typically occurs in older people. The stooped pasture, a masked wooden faces, right? And the rigidity of the back, um reduced arm swing when they walk slightly flexed, knees and hips and short, shuffling gait and tremors. You can typically see both in the upper extremities as well as sometimes in the legs if they were sitting with cross legged posture. Alright. So let's go over each of these three main types of VPs. Dystonia stands to occur in ours is very frightening for the first time uh observer or personal experiences. It, it typically involves a large muscle groups of the face, tongue in hands and you know, the frightening aspect, sometimes your eyeballs roll into your head almost and it's frightening. Um and this is typically treated very acutely with the help of any of the three anti Colin ergic drugs I've just mentioned, often given intra muscularly and sometimes even intravenously. Parkinson Ian side effects like the Parkinson's disease figure cartoon figure that you see on the left is not so fast, typically as acute dystonia and they usually feature at least three of the classic Parkinson Ian features, which is tremors, brady, Kinney Jha and rigidity again, treated with anti Colin ergic drugs. What about a Kathy Jha? This tends to occur also in hours to days to weeks and comes across as fidgety nous, restlessness, inability to sit still, which literally the meaning of apathy Jha and is much more responsive to beta blockers and benzodiazepines. Those sometimes anti Kahlan ergic drugs are used for this condition as well. Okay. So this obviously is the reason for prescribing anti Colin ergic drugs in the first place. The next slide refers to Medical School 101 Pharmacy School, 101, right. The imbalance between dopamine and acetylcholine. So when we have dopamine ergic inhibition caused by dopamine antagonists, then we have, you know Colin ergic excitation, which we need to rebalance by anti Kahlan ergic drugs. And so this is the mechanistic reason for our practice. And the next slide talks about what are the arguments for continuing these drugs forever for life. But if antipsychotic drugs have to be prescribed for life, wouldn't it stand to reason that drugs used for their side effects like E P S should also be used for life? The argument against um not unexpectedly is people adapt to mps over weeks and months and typically don't need this often, don't need it beyond 3-6 months. Um And even more, arguably why you should taper and stop them is the side effects that they themselves break dry mouth, blurred vision, constipation, urinary retention, tachycardia and memory problems. And so these are the reasons for arguing against their long term years, which brings us to the next slide, which is where I hand off to Dr Lupo who had just introduced and she will begin. Thank you so much, Dr Chang Pa. First, I think it's important to understand how anti colon ergic medications like Ben's Trippin and try hex often it'll, that we use for E P S can contribute to our overall anti Colin ergic burden. So, let's talk a little bit about how we quantify anti colon ergic burden and clinical practice. Um, just to define, you know, what we typically refer to as anti colon ergic burden is really the cumulative effect of taking one or more drugs that can induce antique allergic adverse effects. Um And then it can be quantified either through serum radio receptor anti Colin ergic activity essay or using anti Colin ergic burden scales which are expert based lists. Now the S A is sort of perhaps not the most practical for clinical practice. It measures serum anti coal energy city by a blood draw. Um And you know, it can be difficult, especially, you know, if we're hoping to kind of do this across our patient populations. Um and not really as part of a study to, to do this regularly and routinely in clinical practice. Um And really this is why I think the anti Colin ergic burden scales were developed. Um as I mentioned, they are expert based lists they take into consideration and information about um the serum uh anti Colin ergic activity, but also, you know, examples from the literature um and assign a number to each medication according to its antico energetic properties. Um there are over 20 scales out there, believe last I heard there were 22 that have been described in clinical practice. Um all of them have been recommended for use, but um there have been differences in the quality measures which I will talk about. Um next, these scales usually um use a four point um system. And so um the one that we have been using and the scale that, you know, we really have found to be practical in our practice is called the anti coal energy cognitive burden scale developed by Bostonian colleagues in 2008. And it's been our go to really for the past eight years um for our Q I projects. Um and this particular scale um is uh looks at the overall burden in um has been mostly studied in the elderly populations. Um but it is validated and widely used in literature across the years in 2021, Uh Lissie Bock and colleagues published a review of 19 of the ACB scales out there and they did find the anti cornered a cognitive burden scale to be the highest quality in terms of rigor of development, clarity of presentation um and really applicability um to clinical practice. And we really um found that these are extremely important for um for our population and for our patients. And we were especially drawn to the scale because of the focus on the cognition aspect and the impact of anti colon ergic cell in cognition. Um Again, this is uh something of great concern in the elderly but it's also a big concern for our patients with psychosis who um typically already have underlying cognitive impairment. So the A C B scales, like many of the others assigns a number from 0 to 3 and zero are medications that have no anti Colin ergic activity. Whereas A three are the medications with established antique allergic effects that impact cognition and increase the risk of delirium. So a total score of three on the scale is considered to be clinically significant in the elderly. And we would argue the same for our patients with schizophrenia and bipolar disorder. So just something to keep in mind as we move on to the next slide and look at some examples of the medications that are listed on the anti coal energy cognitive burden scale. Now, the medications on this A CB scale, um the list was updated um after 2008, again in 2012. But I still want to know that some of our newer antipsychotics approved after 2012 including bricks, peppers, Okura pristine, those have not yet been evaluated and added to this scale. I also want to point out that the list on the slide is not all inclusive. Um Actually the A C B scale and its entirety can be found at the link on the slide. These are just some examples um of the medications that I really want to talk about today. So our anti coal energy that we use for MPS spent stripping and then it'll, you can see are each assigned a score of three. This is the highest score on the CB scale. So somebody being on one of these medications automatically kind of puts them at that clinical, clinically significant um anticlimactic burden level. But if we take a closer look at our column with medications that have a three, we see that our anti psychotics like cloZAPine, OLANZapine and type in our there, we also see diphenhydrAMINE and hydroxide scene which are commonly used for sleep or anxiety. Um And even just kind of a side note, diphenhydrAMINE is over the counter. So a lot of people might use it without even without us even being aware. Um And then also with the score three, we have some of our T C A S like a trip to lean and mean um as well as our anticlimatic bladder agents, which we certainly see a lot of our patients taking looking at the column with the A C B score of two in the middle. I want to point out that some of our muscle relaxants are there like cyclops, print and Carradine. And then um also want to point out a column with a score of one because we have some of our antipsychotics like haloperidol and risperiDONE with an anti Colin ergic burden school score of one. But we also see medications like warfarin and predniSONE and blood pressure, medications like a tunnel all, fourth Caledon and my Topol all um as well as over the counter allergy medicines like satirizing loratadine and grenadine. Um and the anti diarrheal lo para mind. So you can see how easily and quickly um an anti Colin ergic burden score can accumulate and how we can get up two scores of 56, 10, 12, 13, um depending on the patient. Um, we certainly see patients with very complex medication regimens and so it's not atypical to see scores greater than five. And obviously, then we will also see all of the effects, um the side effects, both peripheral and central, so the side effects on cognition. So, on the next slide, um since we've sort of reviewed how, you know, overall anti Colin ergic is quantified using the A C B scale, let's bring the focus back to what we can do to reduce this burden and the associated side effects by tapering and discontinuing antique allergic medications for E P S when we don't need them anymore. Um I'm going to review two out of the three quality improvement projects that we were able to do um over the past um really almost 10 years here. And um We really believe that stopping these medications and reducing the ACB score even by three points could impact our patients from a side effect perspective, from a quality of life perspective. And um also we were hopeful that there would be improvements in memory. So in 2014 or team initiated um our first QI pilot project, um we used a pharmacy report to identify patients on bench tripping or try hex, offended, ill. Um And all of them had a diagnosis of schizophrenia or bipolar disorder. And the clinical pharmacists collaborated with the psychiatry teams to initiate taper and eventual discontinuation of these medications. Um After our first pilot project, we expanded um within our academic clinic, we um sort of got, got some more reports of our patients on these medications and, um, we're able to work with, you know, about twice as many um to help to taper and just continue um, these medications when they were no longer needed. And finally, um, the initiative was expanded into a community psychiatric clinic where clinical pharmacy support was not ready, readily available. And, uh, Dr Gannon will talk a little bit more about our project three later on. So on the next slide, you know, I, I really want to point out some of the, uh, I guess the approach to de prescribing that, that we took as part of our Q I projects. Um because our clinic is very fortunate to have clinical pharmacy support. Um, we were able to work together the Psychiatry team and the clinical pharmacists and the patients um to provide the screening, the counseling, the education, the monitoring and follow up that were very, very important when stopping, really having a conversation about stopping a medication with a patient. So once a patient was identified and the psychiatrist determined that it would be safe to try and taper and discontinue the medication. So typically this is if our patient, um, isn't experiencing bother some E P S currently, um, and if they're psychiatrically stable, we don't certainly want to make any medication changes in our patients who, um, you know, are not, you know, doing well. Um, and then once a psychiatrist determined that this was an option, a referral was made to the clinical pharmacist. And, you know, the first thing that pharmacists do is we compile a complete and accurate list of medications. So we did a medication review. And as part of that review, we, I, we used the anti Conergy Cognitive Burden scale to identify all of the antique allergic medications that the patient was taking, um, and, you know, assigned a total score. Um And then we also used our uh Pittsburgh Antique Allergic Symptoms scale, um, which was developed by our team and Dr Cheng oppa will go ahead and talk about that a little bit later and the development and the details of that scale, but really, it was um sort of a patient friendly scale that we used to help um identify side effects that could be related to their, their anti Colin ergic medications. So that included dry mouth, blurred vision, have fast heartbeat, constipation problems with memory. So we asked, you know, are you experiencing these side effects. Um how often over the past week or so, have you been experiencing these side effects and really how much are they impacting your day to day functioning and quality of life? Um And finally, we measured uh impairment in short term memory using the memory impairment screen for a project to just want to add that, you know, for the, for some of these screens, it feels sort of like perhaps cumbersome or like a lot of different scales. But really these are all just tools that, um I used as, you know, the clinical pharmacist was able to use, um for education, you know, these weren't really, uh none of these screens or um, questionnaires took longer than maybe a minute or two. Um They were almost always, you know, explained to patients both in words and then they were able to see everything in writing. Um, and especially like our past scale opened up really important conversations about side effects that provided uh that opportunity to educate patients about how, you know, the bench tripping might be causing or exacerbating some of these side effects. Um, once they made that connection between this medication and the side effects that they are experiencing, even patients who maybe at first were initially a little bit hesitant, were more likely to be interested in tapering and um, and discontinuing these medications. So patients were counseled to taper slowly. Um, they met with a pharmacist every one or two weeks to monitor for perhaps reemergence of VPs, um or, um, you know, just make sure that they're, that they're doing well and sticking with the, with the de prescribing sort of the tapering plan. And for most patients, the process took at least two or three months, a couple were able to stop their meds, the ones that were on the lower doses in about a month. Um, and some patients took 6-8 months. We really took a very, very slow approach with them to make sure that they were not experiencing EPS and they were comfortable with the process. And the next slide just outlined some of our um results and what we were able to do and see using our different measures. So, um the in project one, that was our small pilot, we had 29 patients that were initially screened, 19 of those were considered appropriate for a medication change and of the 1913 had their medications discontinued and six head dose reduction. So, um, so 45% overall of all the patients that were screened Were able to stop this medication. We saw 50% improvement in side effects as well as 40% improvement in quality of life And 20% improvement in memory recall. And these results were pretty similar in our second sort of expansion project. We had 51 patients recommended for a change. Um and 31 or 60% how the medication discontinued. So that was fantastic. Um and then eight of them had a dose reduction. And again, we saw really improvements in both quality of life and memory in these patients. We were very encouraged by these results. We notice that even between our first two projects, having had some positive and impact and some success stories from, from those patients, um we sort of, you took time to educate the uh psychiatrists and A PPS about the opportunities to Um two D prescribe these medications and to really take a second look when patients come in for their appointments. And we found that many of them, you know, just kind of planting the seed was enough to get the conversation going and stop some of these medications without even necessarily needing to go through that slower process with the clinical pharmacist. Um And, you know, a lot of patients were just giving us positive feedback, um the medication, they were taking less medications for constipation, they were noticing improved memory and overall they were very satisfied and encouraged by the fact that they could be on less medications. So with that, I um will go ahead and introduce Dr Jessica Gannon is going to talk about our third project. Thanks Dr Lu Pu. So project three, um as Dr Lu Pu already briefly introduced was different than the previous two projects in that it was in a community setting. So one of our affiliate ID um community mental health center. So it was outside of academia and they do not have a clinical pharmacist on staff. Um We wanted to try to de prescribe in a, in a real world setting. Um And so we went in knowing um that we were going to use some of the same educational tools that we did in our second project and expand upon those. Um So we taught um the sites, psychiatrists and their nurse practitioners, um more in depth about GPS and use of an energetic medications and strategies for de prescribing. And after presenting that, we met with them periodically to discuss cases where, you know, um if they were meeting with some barriers where they were meeting with success. And then we all also offered prn consultation as needed consultations. Um This was a community setting, I should say with a high number of patients with schizophrenia, with bipolar disorder who were on um antipsychotics. So we weren't surprised when we ran reports from the medical record that we all use at UPMC, the ambulatory medical record to see that there were a fair number of patients getting either ben's trope in tri hexogen adil or both. And we used those reports to help provide administrative support to the prescribing clinicians. So we teamed up with the front desk at the Community Mental Health Center um and as well as their clinic manager and we provided uh reports to each um physician, each uh nurse practitioner of all the patients they had on Ben's Trophy and Sartain. And then, um, we'd have the front desk, um, give them reminders ultimately through the EMR, which we found was the most efficient way to do it. Um, and that was most appreciated by the prescribing clinicians. They would remind them when one of their patients was coming in who may be an appropriate candidate for d prescription. Um, and then we took these reports um and we tracked them over time. Um We would run them and look for changes to see. Um if ben's trapping or tri hexogen, it'll had been de prescribed at the very beginning. Our first report, um we captured that 106 patients um were on either Ben's Tropea or Tri Hexogen. It'll um a couple of patients were actually on both. Um and they were on those medications for six months or more. 20 patients were prescribed one or both medications for less than six months. Alright. So next I uh this brings us to results. So, um by the end of our project period, 29% of patients had had their anti coal energy medications d prescribed um two of those patients did have to restart those medications because they did have a re emergence of E P S. Um We did analyze our results um to determine if there was any relationship with um a type of antipsychotic therapies. Um We didn't find any association with whether or not, the patient was on one or more antipsychotic or what type of antipsychotic they were on either first generation or second generation or um if they were receiving the antipsychotic orally or through a long acting injectable um D prescription, um was also not associated with patient reported sex or race, um nor age or diagnosis. Okay. Next slide through um all three of the projects, um we learned quite a bit about predictors of success and uh potential barriers to a successful deep prescription. Um at the patient level, we found that patients who are more engaged with treatment in general, um who tend to come to appointments and be adherent with medications who are stable. As Dr Lu pointed out, clinical stability is really important and those who trust um their treatment teams um were more likely to successfully engage in an equal energy deep prescription at the clinician level. We found um that physicians and advanced practice providers who um were very committed to evidence based practice, um who were concerned about things like patient quality of life. Um So we're kind of holistic in their stances um and who were collaborative. Um And so who looked at us as kind of extensions of the treatment team, you know, that we were being helpful and, you know, not interfering. Um They tended to be more successful in um de prescribing um in a coal energy um in, in working with their patients. We all we also found very importantly um that prescribing clinicians who feel supported um by their clinical administrators, like they feel they have enough time to spend on things like the prescription. They also tended to be the clinicians who were more likely to be engaged throughout the course of our project. And then on the next slide, um these are some of the barriers to successful d prescription um that we found over the course of our projects. Um, patients who are not adherent, who miss appointments, who don't take medications as prescribed, who are sort of disengaged, um from treatment, um who are distrusting either because of, you know, um their temperament or maybe um disease factors. Um These folks aren't easy to engage in deep prescription and often don't meet with successful deep prescription. Um We've already mentioned clinically unstable folks, you know, don't tend to do well in these type of projects and patients who have extra primal symptoms already, we, we didn't recommend their inclusion and, and it's possible, you know, that their E P S would get worse with deep prescription so that that would be a barrier to their successfully participating. Um, importantly, wanted to point out too that, you know, some of our patients were quite tied to their medication. Um, you know, we, many of us I'm sure have patients who come out of a psychiatric hospital on pretty complex regimen of medications and when they're on that regimen, um for several years um and they take it faithfully, they begin to feel that the entire regimen is essential for their mental health and staying out of the hospital. So sometimes with those patients, understandably when we start start talking about de prescribing a medication and saying, you know, you, you don't really need this, um we can face some resistance with that. And so patients who were um could who had that tie to, to their, an equal energetic. Um you know, sometimes they would opt out of, of participation on the clinician side, you know, physicians and nurse practitioners that we met, who were sort of fearful of change. Um We're less likely to fully participate in the initiative, those who have had failures and the prescriptions, sometimes those get generalized to all medications. Um patient anxiety um can definitely play a role in um not being as apt to a D prescribe medications. Um you know, patient anxiety can um take, you know, an entire 15, 20 minute session to mitigate. Um And so sometimes it just may not seem that it's worth the time to de prescribe when patients are anxious about it. And that also speaks to lack of resources. Uh clinicians who are prescribing clinicians who didn't feel that they had enough time um or didn't have enough support um in the prescription also were less likely to meet with success. Alright, next slide. So overall, our clinical takeaways are that long term and a colon ergic medications can be tapered and stopped in many patients. Um We do recommend a slower taper, as Dr Lebow said in, in our projects, we generally recommended tapers of of 1 to 6 months or longer um that helped with patient adherence to, to our plans and allowed us to more closely monitor for E P S emergence. Um with only education and local support, 30% of patients can taper and stop a CM. That's what we found in project three. And then with embedded clinical pharmacy support, you know, Dr Luke, who presented the rates in projects one and two um where patients and energy were stopped. If you combine that with folks who were able to be tapered, we got up to 70% rates of prescription. So 70% of patients were able to taper or stop their ACM. Um if you do meaningfully engage with patients who are on an equal allergic medications and anti psychotics and um especially if they're having some antique allergic side effects and they don't have GPS and they're clinically stable. If you try to de prescribe them, they will thank you. Um And we think that you will find like we did in our study that this effort will improve your patient's quality of life. So thank you. And I think I will turn it back over to Dr Chandra. Thank you doctor again. And, and you know, that was a very good explication of three projects by doctors Lupo and Gannon along with a whole bunch of clinical pearls. And sometimes given the tools as Dr Lupo was pointing out, it might look overwhelming, but actually a lot of the support tools are just too engage patients and create the more positive successful trajectory that Dr Gannon was talking about. So here are three of the tools we have developed. And another one that's in development. The first one is the Pittsburgh Antique Allergic Symptoms scale. We had an earlier version that we call version 1.0 and the one we've used more recently is 2.0. Um The second one is a patient handout or infographic as we call it. And this was done from Project three. The one that was done in the community because the prescribers that the doctors and nurse practitioners asked us if they could have a print version on an electronic version uh to bring discussion to the point of deep prescription of anti colonic medications. And the third was oriented towards clinicians and if everything was otherwise okay for the prescription, then what would be the guide to get someone to get going? So I'll talk a few minutes about this before we have a couple of live questions. So the next slide. So this is the past scale. The Pittsburgh Antique allergic symptoms scale that we developed here over time used to be 10 items. We brought it down to six. Then we added one quality of life scale at the end. Um And for the overall burden of the side effects, remember this is a self report and the way we ask is we just ask in the last week so that memory is not for a whole lifetime or for a year or for a month even, but more towards the last week. And this helps you sort of get a sense if they're scoring, you know, in the neutral faces 3456, it's pretty bad for single items, let alone a bunch of items. And as Dr Lupo was pointing out, you add up a whole bunch of drugs with anti colony GIC burden. These numbers could increase rapidly just by having menstrual Pinocchio gente and try expendable and are attained. You could be at three on the anti Colin ergic burden scales, right? But here you might be at different numbers, but it's after all, only patients that could easily tell you how bad their dry mouth, blurred vision or constipation or difficulty urinating is, right? All the memory issues with blurred vision, sometimes we find gets mixed up a little bit but not having seen an optometrist ophthalmologist in years, if not for several years. So there's a little more poking around that needs to be done in the short interview. But these could help guide you to see if they see improvements when you taper and stop medicines like pence trope in or try expended. The last question is really important because, because, um, as Dr Gannon was pointing out, if you are able to achieve success, you will see people coming down from a four or five where it's interfering severely that they're drinking water, not stop using laxatives and stopping these laxatives. As Dr Luke who was pointing out, they'll be very grateful and you will see the measures sort of coming downwards towards one and zeros even. So the next scale, um, is uh informatics tool or a patient infographic uh that Dr Luke who primarily developed and we sort of jumped into and finesse to it. And really, it's uh a patient facing to whether it's electronically available or printed out, it doesn't really matter. It gives them a sense of why we might consider maybe using a lower dose or even stopping and how best we might achieve it in conversation with the prescriber. And so this patient education tool the past, they're all copyrighted by the University of Pittsburgh and UPMC. But in general for clinical use, we would, you know, uh give you permission to use it and all you need is to send us an email. So um this copyright is available to anyone who wants to use this clinically for commercial interest. They'll be contacting the university for, you know, use of this in large trials. If it was ever used. The last um slide addresses a support to that small clinical decision support or a clinical guide, it addresses really what doctors? Lupo and Gannon pointed out, you know, the first thing you want to know is the patient clinically stable because if someone's just come out of the hospital, they're not quite stable. And the menstrual pain was given for acute dystonia. I don't think you want to be tapering and discontinuing on the spot. So you wait for a few months, typically six months. Um, and then, you know, you can ask any of these symptoms bothering you that to call allergic side effects symptoms. And you can do uh you know, a basic examination for stiffness for tremors for rigidity. And if none of these are present, then, you know, maybe you could begin this discussion as to whether you want to continue this medicine or is it time to taper and discontinue? And how do you do it? You do it very slowly over 1 to 6 months. If you were at a super low dose, half a milligram, one mg of either of these anti Colin objects, maybe you could go a little faster. But if you were the typical doses of 234 mg of these drugs or higher with they are tan or try expand would want to take longer to discontinue. And that's just, you know, common sense clinical practice. If it re emerges, you can prepare them to sort of go back to the previous dose all the way back to the original dose that kept them comfortable. So you know, you always have that in your bag when you begin this process. And that's really decision making with the help of sharing this information, which we have now begun to call shared decision making of treatment choices in psychiatry practice. Okay. So these are the three tools available for general clinical use. Just send us an email and you know, we would prefer for people to use it as widely as possible. If there are commercial interests interested, then we will direct them to the right people at the University of Pittsburgh and UPMC. Um And at this point, maybe we are down to just references which are in this slide set. And the next slide is resources. Maybe the some of the resources were earlier um on slides that Dr Luke who presented, you know, maybe places where you could go to online and put in say a bunch of medicines, someone's on cloZAPine, you're unlikely to taper and discontinue that. But they might be on bench atropine for maybe excess salivation. There are alternatives for hyper salivation than using bench atropine or try expendable. And you know, you could reduce the score from 6 to 3 by tapering and discontinuing the anti Colin ergic. Now someone might be on say a dose of Filan's opine, but then a second antipsychotic like hella parasol is added to make up what the landscape in doesn't take care of. And suddenly you have E P S and you have a bench strop and added to it, it's unlikely you will discontinue the lands up in. Um, you know, but if you need to drugs to get things going and better then you would have menstrual pain to go after too, you know, lower and get rid of. So we're down to the last five minutes. I'd like to thank all of you for participating. But what I'd like to end these last five minutes is maybe a couple of questions since this is not a live audience. If I may ask those questions of doctors Gannon and Luke, who so Dr Gannon, um, say, you know, you had someone come to, you maintained on clothes of pain but has seasonal allergies. They're taking maybe diphenhydrAMINE for it. They don't like citrusy, seen one of these so called daytime anti histamines. And they also have, um, maybe try hex middle that was used by somebody for hyper salivation. Um How would you go about thinking about de prescribing this patient? Well, first I'd, um, invite the patient to have a conversation, um, about, um, their medication regimen in total. Um, and you know, see if I could share information with them about, um, antique allergic side effects and how their particular combination of medications could lead to that. And then I would ask them questions or if I was, you know, for, as I am to have a tool like the past, uh, I would, you know, review that with them and have them tell me more about the side effects that they may be having. So I would collect information about that. And if I had the past, you know, I could do that in a more formal way, you know, a qualitative way that I could show them and having that visual that the past gives can be very helpful. And then I would um ask them if they'd like to make a change to try to reduce some of these symptoms. And if they said yes, I um would then share information about, you know, options and the, the lowest hanging fruit here to me. Um If they didn't want to change, you know, their diphenhydrAMINE prescription because as you said, Dr Jacob, but there are other medications for allergies that have lower A CB scales. Um I've used Loratadine in such cases. Um But I would talk to them about hyper salivation with cloZAPine and kind of stay standard of care treatments that we have now, which include under the tongue depetro, Priam, nasal spray and atropine eyedrops. Um And we use those now because they're not systemically absorbed. Um and they help with hyper salivation. Um and we do use them quite commonly with, with some success. Yeah, thank you. I think that's a really good approach. And Dr Lupo, you know, as you were saying, there's a whole bunch of drugs that people coming on, young people, not just psychotropics, but several others, for instance, someone may have incontinence. Um, and you know, may be treated with say ox if you did, right? And that may have resolved, it may not have and it may be on top of the lands of bean or the close of being. And uh you know, there may be yet other drugs. How would you go about counseling and reconciling this kind of medication burden with such patients? And how often would you see them if you, if they went the route of deep prescription? Yeah, absolutely. So we see this often and even in the previous example, you know, um, we have medications prescribed by sort of multiple providers addressing multiple different issues and each carrying an antique owner, drink burden that, you know, is, is contributing to side effects. Um, so, so certainly, um, especially, you know, with, with overactive bladder, we have, um, had to collaborate and work with either primary care providers or potentially urologists. Um, to, uh, you know, we can ask some basic questions about whether patients feel like, you know, their overactive bladder symptoms are well controlled. Um, we find typically quite partial response to some of these medications. Um, we are fortunate to have more metric or mirror background now and this medication is, does not have anti carcinogenic properties. Um, and so this is an alternative and it's effective, it can either be added to the regimen or used instead of our bladder anti Colonna tricks, um, to treat overactive bladder. But, um, you know, honestly I've had patients who have chosen to stop all of them because they're not getting enough benefit. Um, and stopping some of these medications changes their quality of life in other ways. So that's always an option conversation. Like Dr Gannon really just said is so important what matters most to a patient. Um, for some, you know, having a tremor in public, um, is very, very embarrassing. Whereas for others, a little bit of a tremor is, you know, can be very normal. It's not bothersome. And um they're very open to, you know, de prescribing bench tripping because um because of some of the other benefits and reducing side effects. Thank you. I think one of the key things in this business is how we coordinate with other specialties when it comes to medicines prescribed by them. But you know, and if patients and if methods of communication, whether they're through electronic records or email or phone calls can certainly set the stage for this deep prescription and a burden of fewer medicines are told. But I'd like to thank you both for your, you know, wisdom and sharing all the clinical pearls you have with the audience and to this audience. I thank you for your attention and please, you know, complete any cmi requirements by taking any post test questions and uh reaching out within the cmi to any contacts you need in terms of getting the cmi So thank you again, both Dr Gannon and Dr Lu Pu and to Joan for recording this presentation by, by everyone. Thank you. Goodbye.

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