In my clinical practice, I often see elderly patients with at least two or three medication charts. These patients often take at least five to ten medications. Among these medications, there will often be medications that are no longer needed or drugs that might be causing more harm than benefit.
Deprescribing is the process of stopping medicines or reducing the dose of medications that may be causing harm or no longer providing benefits. There are many evidence-based guidelines that help clinicians to start drug treatment. However, there is much less evidence to guide reducing or ceasing therapy. Reducing doses or stopping a drug can be difficult. Sometimes the original reason the medication was prescribed is unknown. This is particularly true if it was initiated many years ago or by a different prescriber at a different hospital.
Two principles of a cautious deprescribing approach include:
- Stop one medication at a time; and
- Reduce doses gradually.
When should deprescribing be considered?
As older people often have more medical conditions they are usually prescribed more medications. Sometimes one new drug is started to treat the side effects of another medication. This increases the risk of drug interactions occurring with their existing therapy. One study shows that one in four older people are hospitalised for medication-related problems over the five year period of study.
Adverse drug reactions
Multiple medications sometimes cause harm to the elderly. For example, tricyclic antidepressants may increase the risk of falls, particularly in the frail elderly. Older people tend to be more sensitive to side effects and may take longer to eliminate drugs from the body due to various physiological age-related changes.
Lack of effectiveness
A medication may be initiated to control the symptoms of a disease or prevent or slow the progression of a disease. For example, a proton pump inhibitor may be prescribed for gastro-oesophageal reflux disease (GORD), or an anti-platelet and statin prescribed to minimise the risk of stroke. However, these medications may not always be required for an extended period. Many people have medical conditions that change after a period of time as they age. The same medications that worked well before might not be the best one for them as their disease state changes.
Terminal illness, dementia or frailty
Patients with short life expectancy most likely do not require preventative therapies such as medicines to treat hypertension, osteoporosis and hyperlipidaemia. The potential benefit is unlikely to be significant for such patients. However, the side effects of these agents can be considerable. Focusing on improving quality of life for patients close to the end of life should be the primary goal of therapy.
What is the general approach to deprescribing?
Pharmacists should discuss with the patient the benefits and risks of deprescribing. Patients should be informed that deprescribing is intended to improve their quality of life by ensuring they do not receive unnecessary medicines with either no or minimal benefit and some potential for harm.
Polypharmacy should be identified as it is associated with increased morbidity and mortality. Medications which can cause significant toxicity, have no relevant indication, and are not providing any benefits to the patient should also be highlighted.
- Medications with the highest risk of side effects, e.g. anticholinergic and sedative drugs.
- Medications with least benefits to the patient, e.g. long-term benzodiazepines.
- Medications with complicated dosage regimens or potential drug interactions.
Withdrawal and discontinuation syndromes should be considered. For example, ceasing high doses of a proton pump inhibitor may result in hyperacid secretion with gastrointestinal symptoms. The duration of the weaning process may vary from a few days to a few months. The duration of this process will be affected by the half-life of the medication, the availability of different dose forms to facilitate dose decreases and the response of the patient.
Beta blockers, benzodiazepines, corticosteroids, opioids, and levodopa should always be reduced slowly over weeks and months. In the case of a patient who has taken a benzodiazepine for a prolonged period, it may be worth substituting short-acting benzodiazepines with an equivalent dose of a long-acting benzodiazepine such as diazepam to reduce withdrawal symptoms.
The best practice should be reducing the dose or stopping one drug at a time to minimise any withdrawal impact to the patient.
- Arrange follow-up with the patient to monitor any withdrawal effects, adverse effects, and positive effects.
- Inform patients of the withdrawal plan so they are aware that drugs may be restarted if needed.
- Encourage patients to participate by asking for their feedback.
- Support patients and review the plan if there are any withdrawal symptoms.
In conclusion, deprescribing may benefit patients if it is conducted with a systematic plan and support. It will not only reduce the financial burden (cost of the medicine) for patients but also improve the quality of life by minimising adverse effects and drug interactions.
- Scott IA, Gray LC, Martin JH, Pillans PI, Mitchell CA. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med. 2013; 18(4): 121-4.
- Le Couteur D, Banks E, Gnjidic D, McLachlan A. Deprescribing. Aust Prescr. 2011; 34: 182-5.