Deprescribing
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 in the Society of Hospital Pharmacists of Australia's flagship Journal of Pharmacy Practice and Research (JPPR) in 2003, in an article titled ‘Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications.’[9][additional citation(s) needed]
Demographics
Older people are the heaviest users of medications and frequently take five or more medications (polypharmacy).
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.[12][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. 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.[17] It found no change in mortality[18] and that, if implemented in all residential aged care facilities across Australia, it could save up to $16 million annually.[19]
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.[12]
Targeted deprescribing can improve adherence to other drugs.[5] 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.[20] Research into deprescribing is accumulating, with two papers showing a rapid acceleration in using the word since 2015.[8][3]
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.[21][22]
Risks
It is possible for the patient to develop adverse
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.[25]
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[26] and has been tested in two RCTs.[16] It is available for clinicians to identify medications that can be deprescribed.[26] 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.[27] The ERASE mnemonic stands for "evaluate diagnostic parameters," "resolved conditions," "ageing normally," "select targets," and "eliminate."
Explicit tools
The
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.[33] Tasmanian Medicare Local has created resources to help clinicians deprescribe.[34] 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.[35]
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.[36] Deprescribing rounds in tertiary care hospitals have also been evaluated and shown to improve health-related outcomes.[37]
Barriers and enablers to deprescribing
Barriers
Although many trials have successfully resulted in a reduction in medication use, there are some barriers to deprescribing:
- the prescriber's beliefs, attitudes, knowledge, skills, and behaviour[38]
- the prescriber's work environment, including work setting, health system and cultural factors[38]
- patients' fears about cessation or dislike of medications.[39]
Enablers
- the prescriber's beliefs, attitudes, knowledge, skills, and behaviour[38]
- the prescriber's work environment, including work setting, health system and cultural factors[38]
- the patient's agreement that deprescribing was appropriate,[39]
- a structured process for cessation,[39]
- the patients' need for influences or reasons to cease medication,[39]
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
- Medication Appropriateness Tool for Comorbid Health Conditions During Dementia (MATCH-D)
- Beers Criteria
- Medication discontinuation
- Overmedication
- Drug interaction
References
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- ^ "MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia". www.match-d.com.au. Retrieved 2023-05-31.
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- ^ "Long-Term Care & Residential Care: Evidence-Based Resources". RxFiles. January 2016.
- ^ "Deprescribing Documents now Available for Download". Consultant Pharmacy Services.
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Further reading
- Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. (May 2015). "Reducing inappropriate polypharmacy: the process of deprescribing". JAMA Internal Medicine. 175 (5): 827–834. PMID 25798731.
- Page A, Potter K, Clifford R, McLachlan A, Etherton-Beer C. "Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D): Consensus recommendations from an interdisciplinary panel of experts". International Pharmaceutical Federation (FIP) World Congress 2016.
- "European Journal of Hospital Pharmacology TOC". Eur J Hosp Pharm. 24 (1). Jan 2017. A special issue on deprescribing
- Hilmer SN, Gnjidic D, Le Couteur DG (December 2012). "Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients". Australian Family Physician. 41 (12): 924–928. PMID 23210113.
- Page AT, Potter K, Clifford R, Etherton-Beer C (September 2016). "Deprescribing in older people". Maturitas. 91: 115–134. PMID 27451330.
- Potter K, Page A, Clifford R, Etherton-Beer C (December 2016). "Deprescribing: a guide for medication reviews". Journal of Pharmacy Practice and Research. 46 (4): 358–367. S2CID 78426240.