Deprescribing Clinical Practice Guideline

New guidelines have been published to support safe deprescribing. The University of Western Australia-led guidelines were developed by more than 70 experts and patient representatives. They integrate existing best-practice recommendations and general principles for safe deprescribing.

These guidelines are designed to translate research into practical steps for reducing or stopping inappropriate medicines in older adults.

Background:

Data suggests that medicine-related harm is responsible for at least 250,000 hospital admissions each year in Australia, with an annual cost of around $1.4 billion. Two-thirds of these admissions are potentially preventable.

The World Health Organization (WHO) Medication Without Harm initiatives highlight that unsafe medication practices and medication errors are a leading cause of injury and avoidable harm around the world. The Australian response aimed to reduce avoidable medication errors, adverse drug events and medication-related hospital admissions by 50% over the period to 2025. The three main areas focussed on in this response are:

• Monitoring polypharmacy and responding to inappropriate polypharmacy
• Reducing harm from high-risk medicines; and
• Improving medication safety at transitions of care.

Polypharmacy is a significant issue in Australia, particularly in older adults. The definition of polypharmacy used by Australian Commission on Safety and Quality in Health Care (the Commission) is five or more medicines taken at the same time. This includes prescription, over-the-counter and complementary medicines. The Commission reports that over 40% of people aged 50 years or older take five or more medicines, and over 10% take ten or more medicines.

Polypharmacy in older people is associated with an increased risk of:

• Hospitalisation;
• Functional impairment;
• Geriatric syndromes (e.g. confusion, falls, incontinence, and frailty); and
• Mortality.

While multiple medicines may be clinically indicated, ongoing assessment of a patient’s risk and benefit can identify medicines that are no longer appropriate.

Deprescribing

Deprescribing can improve health outcomes, reduce treatment burden, and enhance quality of life. However, the process can be challenging as many factors must be taken into consideration. This includes the patient’s overall health, quality of life, goals, preferences, affordability, pill burden, health literacy, and medication adherence.

The new clinical practice guideline aims to simplify the deprescribing process by bridging the gap between research and practice. The guideline provides clear and actionable recommendations and strategies to minimise potential risks. The guidelines are intended to be used by health professionals across various settings, including primary care, hospitals, and residential care. The focus is on people 65 years of age and older, with special considerations for Aboriginal and Torres Strait Islander peoples and other disproportionately affected groups.

The guidelines provide deprescribing advice for key drug classes. Some examples are shown below:

Urinary anticholinergics

Overactive bladder is a common condition affecting older adults which can significantly affect quality of life. Urinary anticholinergics can provide symptomatic relief. While their efficacy is often modest, this medication class is associated with significant adverse effects.

Anticholinergic effects include dry mouth, blurred vision, constipation, urinary retention, and cognitive impairment. It is important to remember that these effects are additive, and many medications have anticholinergic properties, even if that is not their primary mechanism of action.

A high cumulative anticholinergic burden in older people is associated with an increased risk of falls, cognitive decline, and higher all-cause mortality.

Consideration of deprescribing is recommend in the following cases:

• Patients with cognitive impairment, delirium, dementia, or a high risk of falls. The risk of adverse cognitive outcomes and sedation may outweigh the benefits of ongoing use in these patients, particularly for those with a high anticholinergic burden;
• Where no clear indication exists or no identifiable benefit; or
• For drug-induced symptoms where the original drug can be suitably reduced, discontinued, or replaced by another drug.

A comprehensive medication review is also highly recommended for all older people receiving multiple medications with anticholinergic properties.

Proton pump inhibitors (PPIs):

While PPIs are effective for the management of many gastric conditions, they are often continued for prolonged periods without an appropriate indication. Underprescribing in people requiring gastroprotection has also been reported, particularly in older patients and those with polypharmacy.

As a class, PPIs are relatively safe when used in accordance with guideline recommendations. However, long-term use has been associated with many adverse effects ranging from nutritional deficiencies to infections and even gastric cancer. Therefore, the guidelines recommend considering deprescribing long-term PPIs when originally used for a short-term condition or where no clear indication exists for ongoing use.

Benzodiazepines

Sleep disturbances are common in older adults and may be compounded by comorbidities such as chronic pain and depression. Non-pharmacological strategies, along with interventions that address any contributing factors, are first-line options. However, sedatives are commonly prescribed and are often continued for longer than recommended.

Chronic use of benzodiazepines is associated with significant harms, including falls, cognitive impairment, and an increased risk of osteoporotic fractures.

The guidelines suggest deprescribing be considered in older people taking a benzodiazepine for more than four weeks for the treatment of insomnia. The risk of harm with long-term use is noted to generally outweigh any potential benefits (except special cases, such as palliative care). If ongoing treatment is considered appropriate, on-demand or intermittent use at the lowest effective dose is preferable.

The guidelines also provide guidance in withdrawal schedules. The evidence supports tapering the dose by 25% every one to four weeks, while monitoring for withdrawal symptoms and sleep quality. Slower tapering strategies may be appropriate for people at higher risk of withdrawal effects, e.g. patients with prolonged duration or high doses of benzodiazepines and those with a history of withdrawal difficulties.

General

The above examples offer targeted approaches to deprescribing specific drug classes. In addition to this, regular medication review is recommended for older people taking multiple long-term medicines. While there is a lack of direct evidence to quantify the benefits and potential harms associated with general deprescribing, consensus-based recommendations have been developed to guide the process.

The guidelines recommend considering deprescribing medicines that meet one of the following categories:

• No clear indication or an obvious contraindication exists, or if there is an inappropriate prescribing cascade;
• Adverse effects or interactions outweigh the potential benefits;
• Used for symptomatic relief, where the symptoms are resolved and unlikely to recur; or
• Used for prevention, when the potential benefits are uncertain or unlikely to be realised.

When medication review identifies a medicine as being suitable for deprescribing, an individualised deprescribing plan should be developed in collaboration with the patient and/or their carer, where appropriate.

Summary

Both prescribing and deprescribing should be collaborative processes involving healthcare professionals, patients, and their families or carers where appropriate. Deprescribing aims to optimise medication regimens by discontinuing unnecessary or harmful medicines and simplifying treatment plans. It acknowledges that a person’s physiology, preferences, and goals change over time.

The deprescribing process requires shared decision-making, agreed actions, clear communication, and ongoing monitoring for benefits and risks. Deprescribing may lead to drug discontinuation, dose reduction, or switching to a new medication that better aligns with the patient’s goals and evidence-based care. Dose tapering is often more acceptable to patients compared to abrupt cessation. Tapering also offers a practical way to determine the lowest effective dose where complete discontinuation is not possible or appropriate.

The new guidelines can be accessed here.