Deprescribing Explained

Deprescribing is a process of tapering or stopping medications to achieve improved health outcomes by reducing exposure to medications that are potentially either harmful or no longer required.[1] Deprescribing is important to consider with changing health and care goals over time, as well as polypharmacy and adverse effects.[2] Deprescribing can improve adherence, cost, and health outcomes but may have adverse drug withdrawal effects. More specifically, deprescribing is the planned and supervised process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects. Deprescribing is usually done because the drug may be causing harm, may no longer be helping the patient, or may be inappropriate for the individual patient's current situation.[3] [4] Deprescribing can help correct polypharmacy and prescription cascade.

Deprescribing is often done with people who have multiple long-term conditions (multimorbidity), older people, and people who have a limited life expectancy.[5] In all of these situations, certain medications may contribute to an increased risk of adverse events, and people may benefit from a reduction in the amount of medication taken. Deprescribing aims to reduce medication burden and harm while maintaining or improving quality of life. "Simply because a patient has tolerated a therapy for a long duration does not mean that it remains an appropriate treatment. Thoughtful review of a patient's medication regimen in the context of any changes in medical status and potential future benefits should occur regularly, and those agents that may no longer be necessary should be considered for a trial of medication discontinuation."[6]

The process of deprescribing is usually planned and supervised by healthcare professionals.[7] To some, the definition of deprescribing includes only completely stopping a medication, while to others, deprescribing also includes dose reduction, which can improve quality of life (minimize side effects) while maintaining benefits.[8]

History

The world’s first published use of the term “deprescribing” was described in 2003 by Michael Woodward in his article titled ‘Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications.' It was published in the Society of Hospital Pharmacists of Australia's flagship Journal of Pharmacy Practice and Research (JPPR).’[9]

Demographics

Older people are the heaviest users of medications and frequently take five or more medications (polypharmacy). Polypharmacy is associated with increased risks of adverse events, drug interactions, falls, hospitalization, cognitive deficits, and mortality.[10] These effects are particularly seen in high-risk prescribing.[11] Thus, optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes.

Evidence base

Deprescribing is considered a potential intervention with reported safety and feasibility.[12] [13] For a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, adverse effects of deprescribing are rare.[14] [15] While deprescribing has been shown to result in fewer medications, it is less certain if deprescribing is associated with significant changes in health outcomes.[16] Although it might be possible and safe to reduce the number of medicines that people use, reversing the potential harms associated with polypharmacy may not always be achievable.[17] Early evidence suggested that deprescribing may reduce premature death, leading to calls to undertake a double-blind study. A placebo-controlled, double-blind, randomized controlled trial was published in 2023. This study undertook deprescribing in people over 65 years living in residential aged care.[18] It found no change in mortality[19] and that, if implemented in all residential aged care facilities across Australia, it could save up to $16 million annually.[20]

Deprescribing medications may improve patient function, generate a higher quality of life, and reduce bothersome signs and symptoms. Deprescribing has been shown to reduce the number of falls people experience but not to change the risk of having the first fall.[12] Most health outcomes remain unchanged as an effect of deprescribing. The absence of a change has been viewed as a positive outcome, as the medications can often be safely withdrawn without altering health outcomes. This absence of an effect means that older people may not miss out on potentially beneficial effects of using medications due to deprescribing.

Targeted deprescribing can improve adherence to other drugs. Deprescribing can reduce the complexity of medication schedules. Complicated schedules are difficult for people to follow correctly.

The product information provided by drug companies provides much information on how to start medications and what to expect when using them. However, it provides little information on when and how to stop medications.[21] Research into deprescribing is accumulating, with two papers showing a rapid acceleration in using the word since 2015.

In people with multiple long-term conditions and polypharmacy, deprescribing represents a complex challenge as clinical guidelines are usually developed for single conditions. In these cases, tools and guidelines like the Beers Criteria and STOPP/START could be used safely by clinicians, but not all patients might benefit from stopping their medication. There is a need for clarity about how much clinicians can do beyond the guidelines and the responsibility they need to take could help them prescribing and deprescribing for complex cases. Further factors that can help clinicians tailor their decisions to the individual are: access to detailed data on the people in their care (including their backgrounds and personal medical goals), discussing plans to stop a medicine already when it is first prescribed, and a good relationship that involves mutual trust and regular discussions on progress. Furthermore, longer appointments for prescribing and deprescribing would allow time to explain the process, explore related concerns, and support making the right decisions.[22] [23]

A review analysed way to improve deprescribing in primary care. It concluded that clearly defined roles and responsibilities, with good communication between multidisciplinary team members, and pharmacists integrated within teams could aid deprescribing. Routine discussions about deprescribing when prescribing, with medication reviews tailored to patients’ needs and preferences could also help. Patients and informal carers should be involved in decisions, and trusted relationships should be built up with professionals allowing continuity of care. Clinicians would also benefit from training and education on deprescribing.[24] [25]

Risks

It is possible for the patient to develop adverse drug withdrawal events (ADWE).[26] These symptoms may be related to the original reason why the medication was prescribed, to withdrawal symptoms or to underlying diseases that medications have masked.[27] For some medications, ADWEs can generally be minimized or avoided by tapering the dose slowly and carefully monitoring for symptoms. Prescribers should be aware of which medications usually require tapering (such as corticosteroids and benzodiazepines) and which can be safely stopped suddenly (such as antibiotics and nonsteroidal anti-inflammatory drugs).

Monitoring

Deprescribing requires detailed follow-up and monitoring, not unlike the attention required when starting a new medication. It is recommended that prescribers frequently monitor "relevant signs, symptom, laboratory or diagnostic tests that were the original indications for starting the medication," as well as for potential withdrawal effects.[15] The recommended schedule for monitoring during deprescribing is at two-week intervals.[28]

Resources to support deprescribing

Implicit tools

Several tools have been published to inform prescribers of inappropriate medications for various patient groups. The most common deprescribing algorithm is validated[29] and has been tested in two RCTs. It is available for clinicians to identify medications that can be deprescribed. It prompts clinicians to consider if it is (1) an inappropriate prescription, (2) adverse effects or interactions that outweigh symptomatic effects or potential future benefits, (3) drugs taken for symptom relief but the symptoms are stable, and (4) drug intended to prevent future severe events but the potential benefit is unlikely to be realized due to limited life expectancy. If the answer to any of the four prompts is yes, then the medication should be considered for deprescribing.

The CEASE algorithm prompts clinicians to consider if the treated condition remains a current concern for their patient.

The ERASE algorithm prompts clinicians to consider whether the treated condition still requires treatment.[30] The ERASE mnemonic stands for "evaluate diagnostic parameters," "resolved conditions," "ageing normally," "select targets," and "eliminate."

Explicit tools

The Beers Criteria and the STOPP/START criteria present medications that may be inappropriate for use in older adults,[31] including drugs associated with high risk of adverse reactions for this population or lacking evidence for their benefits when safer and more effective alternatives exist.[32] Some countries, such as, Australia have their lists of Potentially Inappropriate Medicines.[33] For people with dementia, the Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D)[34] can help clinicians identify when and what to consider deprescribing.[35]

Resources

RxFiles, an academic detailing group based in Saskatchewan, Canada, has developed a tool to help long-term care providers identify potentially inappropriate medications in their residents.[36] Tasmanian Medicare Local has created resources to help clinicians deprescribe.[37] Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER) is a framework to support practitioners in deprescribing.[38]

Practice changes to encourage deprescribing

An expert working group concluded that integrated healthcare provided by multidisciplinary patient-centred teams was the most appropriate approach to promote deprescribing and improve appropriate medication use.[39] Deprescribing rounds in tertiary care hospitals have also been evaluated and shown to improve health-related outcomes.[40]

Barriers and enablers to deprescribing

Barriers

Although many trials have successfully resulted in a reduction in medication use, there are some barriers to deprescribing:

Enablers

The prescriber and patients were shown to have the most significant influence on each other rather than external influences. 9 out of 10 older people said they would be willing to stop one or more medications if their doctor said it was okay.

See also

Further reading

Notes and References

  1. Page A, Clifford R, Potter K, Etherton-Beer C . April 2018 . A concept analysis of deprescribing medications in older people . Journal of Pharmacy Practice and Research . en . 48 . 2 . 132–148 . 10.1002/jppr.1361. 56510472 . free .
  2. Quek HW, Page A, Potter K, Etherton-Beer C . Deprescribing considerations for older people in general practice . Australian Journal of General Practice . 52 . 4 . 173–180 . April 2023 . 37021442 . 10.31128/AJGP-08-22-6547 . 257984022 . free .
  3. Reeve E, Gnjidic D, Long J, Hilmer S . A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice . British Journal of Clinical Pharmacology . 80 . 6 . 1254–1268 . December 2015 . 27006985 . 4693477 . 10.1111/bcp.12732 .
  4. Thompson W, Farrell B . Deprescribing: what is it and what does the evidence tell us? . The Canadian Journal of Hospital Pharmacy . 66 . 3 . 201–202 . May 2013 . 23814291 . 3694945 . 10.4212/cjhp.v66i3.1261 .
  5. Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN . Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes . Clinics in Geriatric Medicine . 28 . 2 . 237–253 . May 2012 . 22500541 . 10.1016/j.cger.2012.01.006 .
  6. Linsky A, Simon SR . Reversing gears: discontinuing medication therapy to prevent adverse events . JAMA Internal Medicine . 173 . 7 . 524–525 . April 2013 . 23459795 . 10.1001/jamainternmed.2013.4068 .
  7. Liacos M, Page AT, Etherton-Beer C . Deprescribing in older people . Australian Prescriber . 43 . 4 . 114–120 . August 2020 . 32921886 . 7450772 . 10.18773/austprescr.2020.033 .
  8. Page A, Clifford R, Potter K, Etherton-Beer C . A concept analysis of deprescribing medications in older people . Journal of Pharmacy Practice and Research . April 2018 . 48 . 2 . 132–148 . 10.1002/jppr.1361 . free .
  9. Woodward MC . Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications . Journal of Pharmacy Practice and Research . Wiley . 33 . 4 . 2003 . 1445-937X . 10.1002/jppr2003334323 . 323–328.
  10. Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ . Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis . Journal of General Internal Medicine . 35 . 11 . 3323–3332 . November 2020 . 32820421 . 7661661 . 10.1007/s11606-020-06089-2 .
  11. Wang K, Alan J, Page AT, Dimopoulos E, Etherton-Beer C . Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review . Maturitas . 151 . 1–14 . September 2021 . 34446273 . 10.1016/j.maturitas.2021.06.004 .
  12. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD . The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis . British Journal of Clinical Pharmacology . 82 . 3 . 583–623 . September 2016 . 27077231 . 5338123 . 10.1111/bcp.12975 .
  13. Page AT, Khalil H, Etherton-Beer C, Clifford R, Potter K . April 2014 . The efficacy of deprescribing interventions on health outcomes in people aged over 65 years: a systematic review protocol . JBI Database of Systematic Reviews and Implementation Reports . en . 12 . 4 . 124–134 . 10.11124/jbisrir-2014-1394 . 2202-4433. free .
  14. Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG . Medication withdrawal trials in people aged 65 years and older: a systematic review . Drugs & Aging . 25 . 12 . 1021–1031 . 2008 . 19021301 . 10.2165/0002512-200825120-00004 . 25414320 .
  15. Garfinkel D, Mangin D . Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy . Archives of Internal Medicine . 170 . 18 . 1648–1654 . October 2010 . 20937924 . 10.1001/archinternmed.2010.355 . free .
  16. Potter K, Flicker L, Page A, Etherton-Beer C . Deprescribing in Frail Older People: A Randomised Controlled Trial . PLOS ONE . 11 . 3 . e0149984 . March 2016 . 26942907 . 4778763 . 10.1371/journal.pone.0149984 . free . 2016PLoSO..1149984P .
  17. Quek . Hui Wen . The effect of deprescribing interventions on mortality and health outcomes in older people: an updated systematic review and meta-analysis . British Journal of Clinical Pharmacology.
  18. Quek HW, Etherton-Beer C, Page A, McLachlan AJ, Lo SY, Naganathan V, Kearney L, Hilmer SN, Comans T, Mangin D, Lindley RI, Potter K . Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation . Archives of Gerontology and Geriatrics . 107 . 104910 . April 2023 . 36565605 . 10.1016/j.archger.2022.104910 .
  19. Etherton-Beer C, Page A, Naganathan V, Potter K, Comans T, Hilmer SN, McLachlan AJ, Lindley RI, Mangin D . Deprescribing to optimise health outcomes for frail older people: a double-blind placebo-controlled randomised controlled trial-outcomes of the Opti-med study . Age and Ageing . 52 . 5 . May 2023 . 37247404 . 10226731 . 10.1093/ageing/afad081 .
  20. Okafor CE, Keramat SA, Comans T, Page AT, Potter K, Hilmer SN, Lindley RI, Mangin D, Naganathan V, Etherton-Beer C . Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis . Journal of the American Medical Directors Association . 25 . 3 . 539–544.e2 . March 2024 . 38307120 . 10.1016/j.jamda.2023.12.016 .
  21. Page A, Clifford R, Potter K, Etherton-Beer C . 2018. Informing deprescribing decisions in older people: does the Product Information contain advice on medication use for older people and medication withdrawal?. Journal of Pharmacy Practice and Research . 48. 2. 149–157. 10.1002/jppr.1362 . 79794144.
  22. 2023-05-18 . How to reduce medications for people with multiple long-term conditions . NIHR Evidence . Plain English summary . en . National Institute for Health and Care Research . 10.3310/nihrevidence_57904. 258801327 .
  23. Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E . Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis . Health Technology Assessment . 26 . 32 . 1–148 . July 2022 . 35894932 . 9376985 . 10.3310/AAFO2475 .
  24. Radcliffe . Eloise . Servin . Renée . Cox . Natalie . Lim . Stephen . Tan . Qian Yue . Howard . Clare . Sheikh . Claire . Rutter . Paul . Latter . Sue . Lown . Mark . Brad . Lawrence . Fraser . Simon D. S. . Bradbury . Katherine . Roberts . Helen C. . Saucedo . Alejandra Recio . 2023-09-25 . What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis . BMC Geriatrics . 23 . 1 . 591 . 10.1186/s12877-023-04256-8 . free . 1471-2318 . 10519081 . 37743469.
  25. 7 May 2024 . How to deprescribe in primary care . NIHR Evidence. 10.3310/nihrevidence_62994 .
  26. Graves T, Hanlon JT, Schmader KE, Landsman PB, Samsa GP, Pieper CF, Weinberger M . Adverse events after discontinuing medications in elderly outpatients . Archives of Internal Medicine . 157 . 19 . 2205–2210 . October 1997 . 9342997 . 10.1001/archinte.1997.00440400055007 .
  27. Woodward MC . Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications . Journal of Pharmacy Practice and Research . December 2003 . 33 . 4 . 323–328 . 10.1002/jppr2003334323 . 73918568 .
  28. Quek HW, Etherton-Beer C, Page A, McLachlan AJ, Lo SY, Naganathan V, Kearney L, Hilmer SN, Comans T, Mangin D, Lindley RI, Potter K . Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation . Archives of Gerontology and Geriatrics . 107 . 104910 . April 2023 . 36565605 . 10.1016/j.archger.2022.104910 . 254917543 .
  29. Page AT, Etherton-Beer CD, Clifford RM, Burrows S, Eames M, Potter K . Deprescribing in frail older people--Do doctors and pharmacists agree? . Research in Social & Administrative Pharmacy . 12 . 3 . 438–449 . 2016-05-01 . 26453002 . 10.1016/j.sapharm.2015.08.011 .
  30. Page A, Etherton-Beer C . Undiagnosing to prevent overprescribing . Maturitas . 123 . 67–72 . May 2019 . 31027680 . 10.1016/j.maturitas.2019.02.010 . free .
  31. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D . STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation . International Journal of Clinical Pharmacology and Therapeutics . 46 . 2 . 72–83 . February 2008 . 18218287 . 10.5414/cpp46072 . 25532572 .
  32. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH . Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts . Archives of Internal Medicine . 163 . 22 . 2716–2724 . 2003-12-08 . 14662625 . 10.1001/archinte.163.22.2716 .
  33. Wang KN, Etherton-Beer CD, Sanfilippo F, Page AT . Development of a list of Australian potentially inappropriate medicines using the Delphi technique . Internal Medicine Journal . February 2024 . 38303674 . 10.1111/imj.16322 . free .
  34. Web site: MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia . 2023-05-31 . www.match-d.com.au . en-US.
  35. Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C . Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel . Internal Medicine Journal . 46 . 10 . 1189–1197 . October 2016 . 27527376 . 5129475 . 10.1111/imj.13215 .
  36. Web site: Long-Term Care & Residential Care: Evidence-Based Resources. January 2016. RxFiles.
  37. Web site: Deprescribing Documents now Available for Download. Consultant Pharmacy Services.
  38. Mangin D, Lamarche L, Templeton JA, Salerno J, Siu H, Trimble J, Ali A, Varughese J, Page A, Etherton-Beer C . Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER) . Drugs & Aging . 40 . 9 . 857–868 . September 2023 . 37603255 . 10450010 . 10.1007/s40266-023-01055-z .
  39. Page AT, Cross AJ, Elliott RA, Pond D, Dooley M, Beanland C, Etherton-Beer CD . Integrate healthcare to provide multidisciplinary consumer-centred medication management: report from a working group formed from the National Stakeholders' Meeting for the Quality Use of Medicines to Optimise Ageing in Older Australians . Journal of Pharmacy Practice and Research . October 2018 . 48 . 5 . 459–466 . 10.1002/jppr.1434 . 81405354 .
  40. Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D . Impact of deprescribing rounds on discharge prescriptions: an interventional trial . International Journal of Clinical Pharmacy . 41 . 1 . 159–166 . February 2019 . 30478496 . 10.1007/s11096-018-0753-2 . 53730423 .
  41. Anderson K, Stowasser D, Freeman C, Scott I . Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis . BMJ Open . 4 . 12 . e006544 . December 2014 . 25488097 . 4265124 . 10.1136/bmjopen-2014-006544 .
  42. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD . Patient barriers to and enablers of deprescribing: a systematic review . Drugs & Aging . 30 . 10 . 793–807 . October 2013 . 23912674 . 10.1007/s40266-013-0106-8 . 13317143 .

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