Deprescribing

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.[1][2] Deprescribing can help correct polypharmacy and prescription cascade.

Deprescription
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Reduce medication burden and harm

Deprescribing is often done with people who have multiple chronic conditions, for older people, and for people who have a limited life expectancy.[3] 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. The goal of deprescribing is 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."[4]

The process of deprescribing is usually planned and supervised by health care professionals. To some, the definition of deprescribing includes only completely stopping a medication while to others, deprescribing also includes dose reduction as this can improve quality of life (minimizing side effects) while maintaining benefit.[5]

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. Thus, optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes.

Evidence base

Deprescribing is a feasible and safe intervention.[6] Deprescribing results in fewer medications with no significant changes in health outcomes.[7] A systematic review of deprescribing studies for a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, concluded that adverse effects of deprescribing were rare.[8][9]

By deprescribing medications, prescribers are often able to 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 that people experience, but not to change the risk of having the first fall.[6] A large systematic review of deprescribing studies found that most health outcomes remained unchanged as an effect of deprescribing.[6] The absence in 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 as a result of deprescribing.

Targeted deprescribing can improve adherence to other drugs.[3] 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 it, though provides very little information on when and how to stop medications.[10] Research in to deprescribing is accumulating, with two papers showing a rapid acceleration in the use of the word since 2015.[5][1]

Risks

It is possible for the patient to develop adverse drug withdrawal events (ADWE).[11] These symptoms may be related to the original reason why the medication was prescribed, to withdrawal symptoms or to underlying diseases that have been masked by medications.[12] 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.[9]

Resources to support deprescribing

Implicit tools

Several tools have been published to make prescribers aware of inappropriate medications for patient groups. The most common deprescribing algorithm is validated[13] and has been tested in two RCTs.[7] It is available for clinicians to use to identify medications that can be deprescribed.[13] It prompts clinicians to consider if it is (1) an inappropriate prescription, (2) adverse effects or interactions that outweigh symptomatic effect or potential future benefits, (3) drugs taken for symptom relief but the symptoms are stable, and (4) drug intended to prevent serious future events but the potential benefit is unlikely to be realised 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 to prompt clinicians to consider if the treated condition remains a current concern for their patient.

The ERASE algorithm prompts clinicians to consider if the treated condition is still requires treatment.[14] 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 the elderly.[15] For people with dementia, the medication appropriateness tool for comorbid health conditions during dementia (MATCH-D) can help clinicians identify when and what to consider deprescribing.[16]

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.[17] Tasmanian Medicare Local have created resources to help clinicians deprescribe.[18]

Practice changes to encourage deprescribing

An expert working group concluded that integrated healthcare provided by multidisciplinary patient-centred teams were the most appropriate approach to promote deprescribing and improve the appropriate medication use.[19] The concept of having de-prescribing rounds in tertiary care hospitals has also been evaluated and shown to potentially improve health related outcomes.[20]

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[21]
  • the prescriber's work environment, including work setting, health system and cultural factors[21]
  • patients' fears about cessation or dislike of medications.[22]

Enablers
  • the prescriber's beliefs, attitudes, knowledge, skills, and behaviour[21]
  • the prescriber's work environment, including work setting, health system and cultural factors[21]
  • the patient's agreement that deprescribing was appropriate,[22]
  • a structured process for cessation,[22]
  • the patients' need for influences or reasons to cease medication,[22]

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

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See also

References
  1. Reeve E, Gnjidic D, Long J, Hilmer S (December 2015). "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): 1254–68. doi:10.1111/bcp.12732. PMC 4693477. PMID 27006985.
  2. Thompson W, Farrell B (May 2013). "Deprescribing: what is it and what does the evidence tell us?". The Canadian Journal of Hospital Pharmacy. 66 (3): 201–2. doi:10.4212/cjhp.v66i3.1261. PMC 3694945. PMID 23814291.
  3. Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN (May 2012). "Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes". Clinics in Geriatric Medicine. 28 (2): 237–53. doi:10.1016/j.cger.2012.01.006. PMID 22500541.
  4. Linsky A, Simon SR (April 2013). "Reversing gears: discontinuing medication therapy to prevent adverse events". JAMA Internal Medicine. 173 (7): 524–5. doi:10.1001/jamainternmed.2013.4068. PMID 23459795.
  5. 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. 48 (2): 132–148. doi:10.1002/jppr.1361.
  6. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD (September 2016). "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. doi:10.1111/bcp.12975. PMC 5338123. PMID 27077231.
  7. Potter K, Flicker L, Page A, Etherton-Beer C (March 2016). "Deprescribing in Frail Older People: A Randomised Controlled Trial". PLOS ONE. 11 (3): e0149984. Bibcode:2016PLoSO..1149984P. doi:10.1371/journal.pone.0149984. PMC 4778763. PMID 26942907.
  8. Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG (2008). "Medication withdrawal trials in people aged 65 years and older: a systematic review". Drugs & Aging. 25 (12): 1021–31. doi:10.2165/0002512-200825120-00004. PMID 19021301.
  9. Garfinkel D, Mangin D (October 2010). "Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy". Archives of Internal Medicine. 170 (18): 1648–54. doi:10.1001/archinternmed.2010.355. PMID 20937924.
  10. 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. doi:10.1002/jppr.1362.
  11. Graves T, Hanlon JT, Schmader KE, Landsman PB, Samsa GP, Pieper CF, Weinberger M (October 1997). "Adverse events after discontinuing medications in elderly outpatients". Archives of Internal Medicine. 157 (19): 2205–10. doi:10.1001/archinte.1997.00440400055007. PMID 9342997.
  12. Woodward, Michael C (December 2003). "Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications". Journal of Pharmacy Practice and Research. 33 (4): 323–328. doi:10.1002/jppr2003334323.
  13. Page AT, Etherton-Beer CD, Clifford RM, Burrows S, Eames M, Potter K (2016-05-01). "Deprescribing in frail older people--Do doctors and pharmacists agree?". Research in Social & Administrative Pharmacy. 12 (3): 438–49. doi:10.1016/j.sapharm.2015.08.011. PMID 26453002.
  14. Page A, Etherton-Beer C (May 2019). "Undiagnosing to prevent overprescribing". Maturitas. 123: 67–72. doi:10.1016/j.maturitas.2019.02.010. PMID 31027680.
  15. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D (February 2008). "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. doi:10.5414/cpp46072. PMID 18218287.
  16. Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C (October 2016). "Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel". Internal Medicine Journal. 46 (10): 1189–1197. doi:10.1111/imj.13215. PMC 5129475. PMID 27527376.
  17. "Long-Term Care & Residential Care: Evidence-Based Resources". RxFiles. January 2016.
  18. "Deprescribing Documents now Available for Download". Consultant Pharmacy Services.
  19. Page AT, Cross AJ, Elliott RA, Pond D, Dooley M, Beanland C, Etherton-Beer CD (October 2018). "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. 48 (5): 459–466. doi:10.1002/jppr.1434.
  20. Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D (February 2019). "Impact of deprescribing rounds on discharge prescriptions: an interventional trial". International Journal of Clinical Pharmacy. 41 (1): 159–166. doi:10.1007/s11096-018-0753-2. PMID 30478496.
  21. Anderson K, Stowasser D, Freeman C, Scott I (December 2014). "Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis". BMJ Open. 4 (12): e006544. doi:10.1136/bmjopen-2014-006544. PMC 4265124. PMID 25488097.
  22. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD (October 2013). "Patient barriers to and enablers of deprescribing: a systematic review". Drugs & Aging. 30 (10): 793–807. doi:10.1007/s40266-013-0106-8. PMID 23912674.

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