Wednesday, March 7, 2018

What Can the Certified Bariatric Educator (CBE) Designation Do for You?

Reflecting back on my past 5 weeks at mdBriefCase, it has truly been a great learning experience for me as I was able to learn so much about obesity as a disease. For my last post I was able to explore the future of obesity management by highlighting the Certified Bariatric Educator (CBE) designation.     

The designation was developed by the Canadian Obesity Network (CON) for healthcare professionals who want to advance their practice in obesity management. It serves to maintain the standards for credentialing and distinguishing healthcare professionals in Canada who have achieved a competency in obesity management and bariatric care.

To understand the CBE designation in its entirety, I had the pleasure of interviewing 2 healthcare professionals on their CBE experience. Daniel Burton is a registered pharmacist practicing in a primary care network (PCN) centre in Calgary who has just obtained his CBE designation. Jennifer Brown is a registered dietitian practicing in the Weight Management Clinic and Bariatric Centre of Excellence at the Ottawa Hospital, who is in the process of completing her CBE exam but turns out to have almost 10 years of experience practicing in the field of obesity.
Why Obesity?
When I spoke to Daniel and Jennifer individually, both of them had slightly different reasons for pursuing a career in obesity and their CBE designation. For Daniel it was to fill a gap in knowledge he identified while working with various types of patients including those living with diabetes, mental health issues and particularly obesity. Daniel felt the gap in knowledge had to be addressed to be able to fulfill the needs and demands of his practice.  As for Jennifer, she too noticed the lack of knowledge around obesity management and the lack of proper treatment patients were receiving. Jennifer says she was “tired of giving the same old prescription of just eat less, move more” and decided to invest her whole career into obesity management and has not turned back since.

The CBE Process
Overall both Daniel and Jennifer found the process of obtaining their CBE to be not too difficult. Daniel completed the Advanced Obesity Management Program on Advancing Practice, whereas Jennifer participated in the Learning Retreat on the Principles and Practice of Interdisciplinary Obesity Management for Dietitians hosted by CON and Dietitians of Canada. Furthermore both of them found the material not too challenging as long as you were willing to read the resources and do some additional research alongside studying for the exam. Jennifer mentioned for someone like her with 10 years of experience practicing in obesity, having the motivation to pursue a CBE might be a challenge for some healthcare professionals. Despite this, she still stresses the importance for everyone to obtain their CBE, from those just entering practice to those with years of experience in the field of obesity. “It validates your education, your understanding and your confidence to be able to perform in this area” she mentions passionately.  

The Biggest Impact of the CBE
Enthusiastically, Daniel mentions that obtaining his CBE has “shaped and reformed” his practice with all his patients. He now has a different thought process in approaching each patient and some portion of the skills he has developed is applied daily to patient care regardless of the condition. “It has made me a much better clinician” Daniel says proudly as he provides an example of a complex patient who had difficulty maintaining his progress in weight management. With the new skills he learned from becoming a CBE, Daniel was able to tailor the management plan for his patient to something more achievable.

When faced with the same question, Jennifer had to think long and hard because to her, the designation would minimally change her practice directly as she has been working in a Bariatric Centre of Excellence for so long. However, she mentioned the CBE designation would set those with the credential above other providers without. Interestingly, Jennifer often reflected back during the interview to the earlier days of her career and wished she had the opportunity to pursue a designation like the CBE.

When I asked Jennifer if she thought the CBE would strengthen the relationship between patients and healthcare providers, she agreed almost immediately. With obesity management still being under serviced, the credential would make “a world of a difference” for patients as it would instill more trust in their providers. This is because the healthcare professionals have taken the necessary steps to learn about their patient’s condition and are now more capable in managing the condition appropriately.

Patient Recognition & Response
To understand how the CBE designation was being integrated into patient care, I asked both Daniel and Jennifer about the recognition of the designation from patients, employers and colleagues. According to Daniel, the patients that were referred to him already had questions regarding weight management before he had become a CBE and once he obtained this credential, the demand for his services has increased. However the most important reason for him though is that he can now provide these services more effectively.

However, Jennifer highlighted that many patients are still not aware that these credentials exist or the resources available to them. That is why she includes information and resources throughout her counselling and group education to equip patients and their family members with the tools to advocate for their own health to their primary care providers. Patients can go into their physicians’ office and ask questions like “Did you know about the Canadian Obesity Network?” or “Do you know that there is a CBE designation that certifies you as a specialist in this area?” and most healthcare providers are very eager to learn to be able to provide the best care to their patients. To Jennifer the CBE is a tool for patient advocacy, because “it’s the support from their primary care providers that are going to really make the biggest impact”.

Recognition from employers and colleagues
Many of Daniel’s physician colleagues are noticing the potential benefits of the CBE and trust him to manage all aspects of patients’ obesity care; from counseling to monitoring and follow-up because of the expertise associated with the designation. Despite being recognized by his colleagues, Daniel comments that employers are still figuring out how to integrate the CBE services into their healthcare practice, as the PCN he works in is currently in the same situation. He explains that the CBE services are not any different than providing care to a patient with diabetes or hypertension since the approach to patient care is similar regardless of the condition.

Being hopeful, Jennifer thinks the new Canadian Clinical Practice Guidelines on the Treatment of Obesity in Adults that are due to be published in 2018-2019 will highlight the importance of the CBE designation. Additionally, the potential shift in obesity management as a chronic disease in healthcare and policy making in the next 5 to 10 years could have a trickledown effect for employers to ensure their employees have this credential when providing obesity care.

Overall, both Daniel and Jennifer are great examples and motivators for any healthcare professional to pursue their CBE, regardless of where they are in their career. Despite being in its infancy, the CBE designation has a lot to offer healthcare professionals and as obesity management progresses in the next few years, the designation will become an important one to have for any practice.

If this post has sparked your interest in obtaining your CBE designation, refer to the Canadian Obesity Network website for more information on how to kick-start your application process. 


Tuesday, February 27, 2018

Q&A with Dr. Sean Wharton: Obesity through the Eyes of an Expert

As a leading expert in the field of obesity and a Canadian Obesity Network (CON) member, Dr. Sean Wharton MD, FRCPC, PharmD has significantly contributed to the field of obesity in terms of research, treatment, education and patient advocacy over the course of his amazing career.

I had the pleasure of interviewing Dr. Wharton to learn about his career focusing on obesity and his thoughts on the various aspects surrounding this chronic disease. He also discusses what we can do as healthcare professionals to better help our patients living with obesity.

The excerpts below are a summary of my interview with him. I hope this interview provides some food for thought on how we currently manage obesity and what changes can be done to improve management for our patients.

Why did you choose to focus on obesity when there are so many other conditions to manage?
As a general internist, I chose to practice obesity medicine as it had a niche for internists that was unfilled by other subspecialties and there was very little focus on it. I felt that a lot of different chronic diseases being managed including diabetes and hypertension were frequently a result of a person's weight, so if you can manage obesity you can manage a lot of the other health conditions that are associated with it. It’s [obesity] a very interesting, new and exciting field to actually tackle.

What is the most frustrating aspect when dealing with patients or other healthcare professionals?
The most frustrating [aspect] in both patients and healthcare providers is a lack of understanding of the biology of weight change as well as the belief that it is [obesity] primarily a lifestyle issue and not a biological medical condition. I encounter this misunderstanding often and I think clinicians and patients want to believe that obesity is a lifestyle issue and they dismiss the fact that it’s a medical condition despite presented with evidence because it doesn't fit with their thought process.

Most of my patients have little understanding of the biological processes and feel that willpower and/or lifestyle changes are all that is needed to be able to keep weight off over the long term.

Are these biases that you mentioned affecting healthcare professionals’ ability to help patients?
Absolutely, these biases affect the clinicians ability to help patients to lose weight because they lack the true understanding of the biology of obesity. It [these biases] ends up impacting their relationship with patients, their ability to be sensitive to a patient's challenges and ability to offer other aspects of healthcare to their patients in a timely fashion.

Comments like “If you just lose some weight then we can do your pap-smear better because how can I do it if you don't lose weight” results in patients feeling embarrassed and unwilling to return. People who struggle with obesity do not visit their doctor as often [as those without] because of the embarrassment and stigma leading to significant decrease level of care which increases their risk of developing further problems. When they [healthcare professionals] tell patients “You can lose weight with just diet and exercise”, the patient becomes discouraged because they know that they can't and they feel that they’re disappointing their physicians, so they don't come back and see them.

How does commercial diets that guarantee weight loss impact practicing evidence based obesity management?
The short term willpower capacity [that these diets promote] is what ends up confusing people because they really believe that short term weight loss equals the ability to continue [losing weight] in the long term if they just keep on fighting. The analogy I like to paint is playing the slot machines in Vegas; you play it over and over again – winning once in a while, which tends to keep you going and thinking that maybe you’ll win big but in the end everybody loses money at the slot machine eventually. Of course there’s a small percentage of people that have won big and they’re held up as examples of what everyone else can achieve. It’s unfortunate because people want to believe in success and they want to believe in the dream but it’s misleading.    

What is the biggest achievement and setback that has occurred in obesity management?
I think the biggest achievement is the introduction of GLP-1 analogues [for obesity treatment] because for the first time the neurological and biological aspects [of obesity] were highlighted by a medication backed by a big pharmaceutical company. This facilitated the education of obesity to a large number of people whereas prior to that, the medications on the market didn't really highlight how much obesity is a biological and neurological process.

The biggest setback I think has been the commercialization of weight loss shows which continue to perpetuate that this [obesity] can be managed through lifestyle modification alone. People only see the initial weight loss success but not the regaining of weight after due to the biology [of obesity].

In your opinion, what are some of the most useful resources for obesity management for both healthcare professionals and patients?
In terms of physician and researcher resources, I found that the Canadian Obesity Network (CON) has been very good. For patient resources I have not found very many that are actually helpful but there are multiple websites that do not provide useful information about the biological aspect of obesity and do nothing to help a patient.

The few [patient resources] that are helpful include Dr. Yoni Freedhoff’s blog and Dr. Sue Pederson’s blog as well as Dr. Freedhoff’s book “The Diet Fix” which is pretty good but it’s a little wordy and not as patient friendly.

When should a general practitioner refer their patients to an obesity specialist?
I think any time a patient expresses that they are feeling lost, having difficulty managing weight and expressing the need to see somebody with greater knowledge. It shouldn’t be based on the patient’s health or weight. Although a patient might not fit the BMI criteria for referral to a weight management clinic, the degree of stress that is associated with weight gain and the need for greater understanding of their bodies is an important consideration. Of course if they have other health conditions associated with elevated weight (e.g. fatty liver, osteoarthritis, diabetes, hypertension and dyslipidemia) they should definitely find their way to an obesity specialist.

What is it the single best thing, as healthcare professionals we can do to reduce the stigma patients experience?
I think the best thing we can do is explain the biology [of obesity] to patients. I believe that not only the physician community but the patient community needs to be aware of it too. This goes a long way in accepting obesity as a medical condition and therefore provides the ability to actually treat it. By explaining to patients the biological process that dictates the weight gained once weight has been lost, it helps them understand their struggle and reduce the self-blame which can significantly affect their goals. With the appropriate goals, patients have a greater ability to be happy and self-efficacious.

Post Reflection
After speaking with Dr. Wharton, I could feel the immense passion he has for the field of obesity and it is exciting to see how the future of obesity management and treatment will change as more research is being conducted in different areas from pharmacotherapy, surgery to psychology.

For more information on topics discussed in the interview, here are some links:


Wednesday, February 14, 2018

Q&A with Dawn Hatanaka: Exploring the Canadian Obesity Network

Although it is Canada's largest obesity association, made up of healthcare professionals, researchers, policy makers and people with an interest in obesity, I had not heard of the Canadian Obesity Network (CON) prior to my rotation at mdBriefCase.

In the excerpts below, I’ve summarized my interview with Dawn Hatanaka, the Director of Education for CON, who is responsible for the organization’s educational initiatives. Dawn explains the association’s origins, goals, achievements as well as what we can expect from the future of CON. I’m hoping that after sharing this excerpt, more healthcare professionals will be aware of CON as both an organization and its offerings.

What is the Canadian Obesity Network and why was it created? 
The Canadian Obesity Network - Réseau canadien en obésité, or CON-RCO, is our official acronym and I like to think we’re Canada’s authority on evidence-based approaches for obesity prevention, treatment and policy. CON-RCO was started in 2006 to create a coordinated response to obesity care; from prevention, treatment to policy across the board. 

When we launched, everything was siloed and piecemealed across the country, so the thought was the network would join obesity research and funding along with prevention and treatment strategies. As of January 2018, the network has about 15,000 professional members and we just opened to the public in 2015 with around 2,000 public supporters. 

You mentioned CON started targeting a scientific community but later opened to the public for membership. Why the change? 
Our mission has always been to improve the lives of Canadians affected by obesity but to do so, we needed to reach out to them. At a 2015 CON workshop – which brought together people living with obesity, healthcare professionals, researchers, policy makers and collaborators - everyone agreed that Canadians living with obesity needed a credible source of resources about their health and how to advocate for themselves. So in June of 2015, the Public Engagement Committee was established, where all members are people living with obesity in Canada and managing their obesity in different ways. They’re our spokespeople across the country for the public and have actively participated in activities to help raise the voice of Canadians affected with obesity, through social media, media interviews, speaker bureaus, education activities and practice and policy committees around the country. 

What would you say are CON’s current goals right now? 
Our official goals are addressing social stigma associated with obesity, changing the way policy makers and health professionals approach obesity and improving access to evidence-based prevention and treatment resources. 
While we continue with what one could say are lofty goals, the things we do to reach them change yearly. We continue to deliver education programs for healthcare professionals, we’ve partnered with government agencies and others working in population health policies because there has been a lot of unintentional consequences of population health messaging which deter people from seeking out treatment due to that stigma. We’re also supporting obesity research, through collaboration with the Canadian Institute of Health Research (CIHR) and leveraging 1.5 billion dollars in funding for obesity research. 

Many of the myths and messages in the public are very patient centric. What are the major initiatives CON has spearheaded recently to combat these myths? 
Last year we started a “Bust The Bias” campaign over social media only. These short videos [on CON’s YouTube channel] talk about all these myths and why they’re wrong. We placed them in the public eye and shared them with our partner associations to increase people’s exposure to the content. For example, the bariatric clinic in Ottawa have all of them rolling on their TVs in the waiting room all the time. 

What would you say is the biggest challenge the network faces as an organization? 
Getting obesity recognized as a chronic disease across the board is our biggest challenge so far. Despite CON-RCO, Canadian Medical Association, American Medical Association and the WHO declaring obesity to be a chronic disease, the provinces and territories don’t recognize it as a chronic disease nor do they treat it that way. They still categorize obesity as a result of poor lifestyle choices.

Obesity is not on their radar and I think it’s one of the things that CON-RCO needs to do; mobilize that advocacy side and the public to ask because you’re never going to get something if you don’t ask. 

What would you say are the key milestones CON has made since its inception? 
There are a couple of key things. The number of Canadian physicians taking the American Board of Obesity Management (ABOM) exam almost doubled between 2016 and 2017. We also launched the Certified Bariatric Educator program in 2016, which started out with very small numbers but continues to grow with interest in Canada as well as internationally.

I also think with the CMA declaring obesity as a chronic medical disease in October 2015 was a big thing. We had champions within the CMA that had been pushing this agenda forward for years. Of course, the report card that was released last year was huge because you can finally put some numbers and grades to show people [the issues surrounding access to obesity treatments]. 

Where would you like to see CON in the next 5-10 years and what steps must be taken to get there? 
Provincial and territorial governments need to recognize the position that CMA and CON have taken - that obesity is a chronic disease and they need to put resources towards it and change their approach accordingly. I’d also like to see employers & health insurers do the same – that would be amazing.

That’s where I think we should go - getting obesity recognized as a chronic disease across the board, which will have a trickle-down effect to increase access to care. We still have a lot more work in the weight bias and stigma space to get people to recognize weight bias and stigma as barriers preventing people from accessing treatment for their chronic disease.

I’ll also mention that we’ve just started writing new Canadian clinical practice guidelines for the management and treatment of obesity in adults which should be released in early 2019. This one is going to be quite different, as the target audience is family physicians and it will be patient-centered. We also have people living with obesity as part of the committee. One of the things the patient group is suggesting is that we have a patient tool kit included so they can talk to their physician and help promote the uptake as well. 

Post Reflection 

After speaking to Dawn, I realized how much CON has to offer to healthcare professionals and to patients as well. It’s also free for healthcare professionals to join and access the various resources available from the Network regarding obesity management. For more information on topics discussed in the interview, please see below for some links:


Monday, February 5, 2018

5 Misconceptions Every Pharmacy Student Probably Has About Obesity

Obesity is in some ways like trying to fix a pipe leak – we think we know how to do it, yet 5 minutes into an overflowing washroom, we’re calling the plumber.  

That is exactly how I felt when I was completing the Advanced Obesity Management Program (AOMP) on Advancing Practice, I thought I understood obesity but in fact I had a lot to learn. As a 4th year pharmacy student on the cusp of becoming a licensed pharmacist, I was shocked at how little I knew about obesity as a disease and its management. Even though the prevalence of obesity is widespread, there is still a large knowledge gap among many healthcare professionals; especially pharmacists in my opinion.

Here are the 5 greatest misconceptions I feel pharmacy students have on obesity, which I have also experienced:

Misconception #1: Obesity is solely caused by excessive eating and/or lack of physical activity
From the AOMP, I have learned that obesity is much more complex than just “energy in” versus “energy out”. Important contributors such as genetic pre-disposition, insufficient sleep, psychological stress, hormonal imbalance and medications, have compelling supporting evidence in the development of obesity.1

Misconception #2: Obesity is a risk factor for disease, it is not a chronic disease itself
Obesity is in fact both a risk factor and chronic disease itself, similarly to hypertension. Although pharmacists are well aware that obesity can increase the risk of other diseases (e.g. type 2 diabetes, obstructive sleep apnea, hypertension etc.), it is also important to acknowledge obesity as a chronic disease. This would allow us to change how we manage obesity as well as help reduce the stigma surrounding it.2

Misconception #3: Patients’ willpower and self-control determines their ability to lose weight and keep it off
A patient may be successful in losing weight but the maintenance of weight loss is hard. Despite putting in more effort into a weight loss program, it does not always result in additional weight loss. When I learned that our bodies had an inherent compensatory to maintain our “highest weight”, I had a deeper appreciation for the fight patients had to go through.1 This explains the difficulty of maintaining and further achieving weight loss.

Misconception #4: Body Mass Index (BMI) can be used to define obesity 
For a very long time, I believed BMI was a number that determined if a patient had obesity or not. However, the Canadian Medical Association recommends using clinical measures of health rather than diagnosing obesity with BMI values as it measures body size.2-3 Although BMI can be a useful tool to glean insight into a patient’s health status, it should not be the sole measure of obesity.

Misconception #5: Pharmacists do not have a role in obesity management 
I have been guilty of providing the oversimplified “Eat less, move more” response to patients seeking weight loss advice in the pharmacy and often, would redirect patients to dieticians or family physicians. However, as frontline healthcare workers, we are in the perfect position to initiate conversations about obesity, arrange follow-up monitoring, and provide patient support and encouragement. Most pertinent to our practice is preventing weight gain caused by certain medications dispensed regularly by providing weight management strategies beforehand.

It is definitely a difficult feat to manage obesity, especially when the individuals that patients turn to for help already have misconceptions about the disease and/or patient. Hopefully, as healthcare professionals, we can further educate ourselves on obesity and try to move away from our own biases to help make a significant impact on this disease. To learn more about obesity, click below to discover Advancing Practice’s continuing education program and become certified as a Bariatric Educator:

If you are itching to delve into the obesity conversation, look out for my 3-part interview series where various experts weigh in on the subject of obesity, no pun intended!


  1.  Chaput, J.-P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician60(11), 973–975.
  2.  An Obesity Manifesto: Debunking the Myths - Medscape - Feb 23, 2017. Retrieved from
  3. Rich P. CMA recognizes obesity as a disease. Oct 9, 2015. Retrieved from

Thursday, January 25, 2018

The Newest Kid on the Block

Hi mdBriefCase team!

My name is Aveline and I’m the latest 4th year pharmacy student from UofT completing my rotation at mdBriefCase. This will be my second last rotation before I nose-dive into my books for my licensing exam this coming May and face the (scary) real world.

It was a pleasure meeting most of the office today and I hope to get to know everyone a little better as I complete my 5 weeks of rotation here.

Some fun facts about me:
  • I love baking! My dream is to own a double-door oven.
  • I’m obsessed with Lego and I’ve recently obtained a model set of the Taj Mahal.
  • Dogs and classical art memes are my kryptonite.
  • The spelling of my name has been the bane of my existence; Ellen, Eveline, Evelyn, Avelyn. I’ve heard it all.

mdBriefCase will be my first experience in a non-direct patient care setting and it will definitely be a 180 degree flip from what I’m used to, but I shall fear not and accept the challenges ahead. I intend to make the most of my time here, so I hope you don’t mind me asking tons of questions. 😊

Please look forward to my blog posts, newsletter and presentation in the upcoming 5 weeks!

Aveline Tung 

Friday, December 1, 2017

Tramadol: A Case of Misclassification?

Although tramadol was being considered for classification as a controlled drug back in 2007, it remained an uncontrolled drug.1 A decade later, Health Canada is reconsidering the decision and may re-categorize tramadol as an opioid.1

Tramadol is a painkiller that increases serotonin levels in the body like antidepressants do, leading to some analgesia.1 In addition, CYP2D6 in the liver then converts tramadol to a compound called M1, which is an opioid that provides pain relief similarly to morphine.1 One thing to remember is the pharmacogenomics involved with the conversion of tramadol to M1.1 Some individuals have weak CYP2D6 activity and do not receive the opioid effect, whereas, others may have rapid conversion and acquire a large opioid effect.1

The classification of Tramadol as an opioid is being contemplated due to multiple health care professionals voicing concerns as well as a report on opioid trends from the Canadian Institute for Health Information (CIHI) released last week.2 According to the report, tramadol prescriptions have increased 30% and daily doses have increased by 23% between 2012 and 2016.3 Despite the Canadian non-opioid classification, CIHI included tramadol in their report on opioids because the World Health Organization classifies it as an opioid, as does the United States’ Drug Enforcement Administration and the manufacturers' scientific description.2

Tramadol has the potential to be abused, misused, and can cause dependence especially at higher doses.2,4 Its classification as a non-opioid makes for minimal reporting requirements resulting in a lack of data to help us measure the extent of its abuse and misuse in Canada.2

The opioid crisis does not look like it will resolve any time soon as there is no simple solution for the problem. Therefore, making even the smallest of changes, such as modifying the classification of tramadol to an opioid and the resulting alterations in reporting requirements, could prove crucial.

Now we wait and see if Health Canada will make this change.

1. Juurlink, D. (2017, November 27). Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail. Retrieved from

2. Howlett, K. (2017, November 22). Health Canada eyes opioid restrictions for popular painkiller. The Globe and Mail. Retrieved from

3. Canadian Institute for Health Information. (2017). Pan-Canadian Trends in the Prescribing of Opioids. Ontario: Canadian Institute for Health Information. Retrieved from

4Purdue Pharma. (2016). PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION : Zytram XL®. Pickering. Retrieved from

Thursday, November 23, 2017

Being a Wise Pharmacist

The Canadian Pharmacist Association (CPhA) just released a campaign called Choosing Wisely Canada for pharmacists.1 This campaign was created to help pharmacists have discussions with patients to identify if treatments are warranted, have evidence to support use, and/or can cause harm to patients.1 The recommendations were made by asking Canadian pharmacists and pharmacy researchers to provide their input, which were then reviewed by an expert committee.The final list was created considering the relevance to pharmacy practice, possible impact and supporting evidence.1 The six evidence-based recommendations were made for pharmacists to help optimize patient care and safety.1

1.   Don’t use a medication to treat the side effects of another medication unless absolutely necessary.2

It is important to clarify if a symptom is part of a medical condition or a side effect to a medication.2 You do not want to initiate a prescribing cascade, as it can lead to polypharmacy.2 The polypharmacy can then generate to more side effects, drug interactions, impact adherence and patient’s quality of life.2

For more information read: The prescribing cascade revisited.

2.   Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain.2 Counsel patients against their use and recommend safe alternatives.2

According to evidence, use of over-the-counter pain medication containing codeine is not supported over non-opioid options.2 Codeine has the potential to be abused and cause dependence.2 Furthermore, the codeine containing medications tend to have high doses of the simple analgesics (acetaminophen, aspirin or ibuprofen) which can cause adverse effects with misuse (i.e. liver toxicity, peptic ulcers and renal damage).2 
3.   Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient. 2

About 66% of Canadians over the age of 65 take five or more drugs.2 Polypharmacy increases risk of adverse drug reactions and can lead to hospitalization.2 Pharmacists should clarify the therapeutic indication for all medications and only renew prescriptions if benefits of therapy are known to be greater than the risks.2

A tool to help with this task: Check up on “checking”

4.   Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.2

PPIs are safe and well-tolerated for short term use in of gastroesophageal reflux disease, but can cause adverse effects if used long term, such as: increased risk of fracture, C. difficile infection and diarrhea, community-acquired pneumonia (CAP), hypocobalaminemia and hypomagnesemia.2 Recommend H2-receptor antagonists or lifestyle changes for patients that have used PPIs for 4 weeks and are no longer symptomatic.2 Note: This recommendation does not apply for Barrett esophagus, severe esophagitis grade C or D, or known history of bleeding gastrointestinal ulcers.2

Tools to help with this task: Bye-Bye PPI and PPI Deprescribing Algorithm

5.   Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.2

Many people have been using antipsychotics for an off-label indication of insomnia.However, there is no evidence to support first-line use in guidelines and there are side effects to consider (i.e. weight gain and metabolic disorders).2

6.   Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).2

Benzodiazepines are often prescribed for anxiety disorders and insomnia.2 Long term use in elderly patients can lead to tolerance, dependence, adverse effects (i.e. sedation, impaired memory, falls) and hospitalization.2 Guidelines recommend using other options before benzodiazepines.2 If prescribed they should not be used long term and a treatment plan should be developed (i.e. taper schedule).2

A tool to help with this task: Benzodiazepine and Z-drug Deprescribing Algorithm

These six changes have the potential to make a large impact on patient care and safety. What do you think about these new recommendations? Email me to share your success stories.

A video of the recommendations available as well: 6 Things Pharmacists & Patients Should Question - Choosing Wisely Canada


     1. Canadian Pharmacists Association. (2017, November 21). Choosing Wisely Canada. Retrieved from

     2. Canadian Pharmacists Association. (2017, November). Six Things Pharmacists and Patients Should Question. Retrieved from