Easy to Start, Hard to Stop: Polypharmacy and Deprescribing

Linda Brookes, MSc

Disclosures

June 01, 2017

Guidelines for Deprescribing

Lists of potentially inappropriate medications that can be used as tools for deprescribing in older adults include the Beers criteria, as recently updated by the American Geriatrics Society,[12] and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment).[13] Application of these tools has been shown to reduce the use of these agents,[14] but it is unclear whether they significantly improve such outcomes as hospital admissions, medication-related problems, or overall quality of life.[15]

Current clinical practice guidelines do not typically take into consideration the long-term net benefits and harms associated with all medications that older patients with multiple chronic conditions would be taking if evidence-based guidelines for each condition were followed.[16,17] Clinicians complain about the number of different treatment guidelines that they have to consult and the complexities of risk/benefit assessments in these patients.[18] "All the clinical guidelines tell you how to start drugs, but not how to stop them. So we thought, why don't we try to create a deprescribing guideline, following the same rigorous processes that you would use for an evidence-based prescribing guideline," Dr Farrell recalls.

As part of their "Deprescribing Guidelines for the Elderly" project, Dr Farrell and colleagues used evidence-based approaches and guideline assessment tools to develop guidelines for specific drug classes identified as priorities for clinicians.[19,20] The first four guidelines cover deprescribing proton pump inhibitors, benzodiazepine receptor agonists, antipsychotics, and antihyperglycemics, all of which are accompanied by decision-support tools in the form of algorithms.[21] A fifth guideline in preparation will cover acetylcholinesterase inhibitors in the treatment of dementia. The group is hoping to get funding to develop additional guidelines for statins, bisphosphonates, and antihypertensive agents.

"Ideally, in the next 10 years, I would like to see all prescribing guidelines have deprescribing sections, so that people can see, in a patient with a certain condition, not only when to start a drug but also the reasons for decreasing the dose or stopping the drug later, and how to go about it," says Dr Farrell. Her group has recently been in discussion with Hypertension Canada about working in partnership to include guidance on deprescribing in the Canadian Hypertension Education Program treatment guidelines.

Challenges for Implementation

Despite increased awareness about the need for more deprescribing, there is "nothing in primary care right now mandates that older patients must have medication reviews, and nothing that says exactly what constitutes a medication review," Dr Farrell cautions. In Ontario, patients in residential care must have a medication review every 3 months, but the quality of that review varies widely, she notes.

"Another challenge is the lack of consistency in the proportion of teaching about geriatrics, let alone polypharmacy and deprescribing, in medical, pharmacy, and nursing education," she adds. "We are trying to promote incorporation of those competencies into undergraduate curricula."

In the meantime, research is needed to support the benefits of deprescribing over "usual care," Dr Farrell suggests. Experimental and observational studies to date show deprescribing to be feasible, safe, and associated with some benefits, although reductions in mortality have not been shown consistently.[22]

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