Hello. I am Dr Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine in Washington, DC. Today I am going to talk about the issue of deprescribing.
"Deprescribing" is a relatively new term, first appearing in the literature in 2003. It concerns the overuse of medications, or use of certain ones for too long—in general, polypharmacy. Deprescribing is defined as the process of withdrawal of an inappropriate medication, supervised by a healthcare professional, with the goal of managing polypharmacy and improving outcomes.
Polypharmacy and potentially inappropriate medications have been associated with many negative health outcomes, including reduced quality of life, adverse drug reactions, addiction, falls, nonadherence, hospitalizations, and mortality. Other considerations to support deprescribing include reduced cost and perhaps even improved patient adherence.
Currently, there are few available studies on polypharmacy, with most of those that exist focusing on reducing polypharmacy and the number of medications prescribed. Few studies have looked at actual clinical outcomes, such as improved mortality and reduced hospital admissions. We do not really know that much about the outcomes of deprescribing just yet.
There are some data that have shown that patients actually want to take fewer medications, but in reality, we as physicians do not really know how to do it and do not do it as much as we perhaps should. Studies looking at physician barriers address such issues as lack of awareness, meaning our own insight into the appropriateness of our prescribing and deprescribing; inertia, the failure to act despite the awareness of the benefits of deprescribing; self-efficacy, having the skills, knowledge, attitudes, and the information to deprescribe; and, finally, the feasibility of it—having the time in practice to do it and the medical culture influences to support it.
Picking a Plan That Works
Deprescribing, for obvious reasons, should be a shared decision-making process. We can talk about dose reduction and switching to other safer medications, or we can talk about tapering and stopping the medication altogether.
How do we do it? The first step would be to collect a complete and comprehensive medication history that includes supplements and vitamins. We have to assess the patient's adherence to the medications and the overall risks and benefits depending on individual patient factors. We want to talk about the patients' and caregivers' values and preferences, and the goals of care surrounding those medications and their continuation.
There are drug-related factors that need to be taken into account, including polypharmacy, the pill burden, the medication regimen, drug/drug interactions, and the use of specific high-risk drugs. Patient factors to consider are life expectancy, cognitive and functional factors, what kind of impairment the medications are causing (from fall risk to comorbidities), multiple prescribers, and palliative care.
When we begin the process of deprescribing, we need to figure out which medications are most important to the patient. We then have to identify the potentially inappropriate medications that they are on and consider medications that they are on without any specific indication—either the condition has resolved, or we do not know why they are taking it. Then we should note whether a medication has questionable efficacy or alters the risk in combination with other medications, at which point we should obviously talk about adverse drug reactions and potential for future harm.
There are specific tools that we can use for using explicit lists of medications that are inappropriate in older adults; these include the Beers criteria and the Screening Tool for Older Persons' Prescriptions (STOPP) criteria.
When we decide on the medication withdrawal, we need to prioritize what we want to start with first.
When is the appropriate time? Anytime, but we need to consider such questions as whether the medication is known to cause withdrawal symptoms. MedStopper.com is a really good resource for this. Are we talking about a slow dose reduction before an altogether discontinuation? We need to monitor for the benefits as well as the harms of medication withdrawal.
We need to plan the tapering or withdrawal process and monitor it with very specific documentation and communications to everybody involved: the patient, their caregivers, and perhaps other clinicians caring for the same patient. We then create a management plan, what symptoms to look for, what the action plan is, and what kind of monitoring is required by us, and then whom to contact should there be any side effects or withdrawal symptoms.[4,5]
There are several guidelines to hone this process. There are decision support tools and specific algorithms that are very useful for proton pump inhibitors, benzodiazepines, certain antipsychotics, and antihyperglycemics, which you can find at the website deprescribing.org.
At this point, there is some evidence supporting the benefits and safety of deprescribing. Although not very robust, the body of literature is growing as we speak. There are tools out there to help. We just need to be committed to the idea that deprescribing is a good process, and then help change the culture of medicine by doing it.
Risk: Making Medicines Safer for All of Us
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Cite this: Targeting Unnecessary Meds: A Guide to Deprescribing - Medscape - Jun 09, 2017.