Introduction
Deprescribing is an essential part of good prescribing and is inherently linked to related activities, such as medication reconciliation, to ensure safe and effective use of medications. This process requires attention, time, and in many cases special skills and knowledge. This includes technical knowledge, such as optimal down-titration schedules, as well as competencies in shared decision-making, communication, and managing health systems in a medical culture that historically has been more oriented toward adding medications than stopping them.
Deprescribing is most commonly employed in geriatric or palliative care patients, although it can be appropriate in other patients as well.
Definition
The term “deprescribing” refers to a process of medication withdrawal, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes1. This can encompass efforts to comprehensively review a patient’s medication list and systematically discontinue or reduce the dose of all medications with an unfavorable balance of benefits and harms, as well as efforts focused on specific types of high-risk medication. What distinguishes deprescribing from traditional approaches to pharmaceutical care is that it encourages a systematic and proactive approach. Identifying an adverse drug event and stopping the offending medication is good medical care but is also reactive to existing problems or complaints. Deprescribing focuses on being proactive to address medication-related problems that have not previously been identified or satisfactorily managed and to prevent future problems
Goals of Deprescribing
Common goals for deprescribing include reducing overall medication burden, reducing the risk of specific geriatric syndromes such as falls and cognitive impairment, and improving global health outcomes such as hospitalization and death. Ultimately, all these goals relate to improving quality of life. Specific goals can include:
- Reducing medication burden – Careful medication review and aggressive discontinuation can lead to reduction of medications used, including reducing use of potentially inappropriate medications. Reducing medication burden may improve adherence to remaining medications.
- Reducing risk of falls – Many medications increase fall risk among older adults, including benzodiazepines and benzodiazepine receptor agonists antidepressants, antipsychotics, and strongly anticholinergic medications. In nursing home settings, deprescribing programs using broad-based medication review have been shown to reduce fall risk by 24 percent2.
- Improving and/or preserving cognitive function – Anticholinergic medications, sedative-hypnotics including benzodiazepines and benzodiazepine receptor agonists, and use of multiple psychotropic medications can negatively affect cognition. Discontinuation of benzodiazepines has been shown to improve cognitive function in nursing home residents and elderly patients.
- Reduce risk of hospitalization and death – In vulnerable older adults residing in nursing homes, trials of interventions incorporating whole-regimen review and deprescribing reduced hospitalization by 36 percent and death by 26 to 38 percent2. In ambulatory settings, a systematic review found that interventions using whole-medication review had no impact on hospitalization but did reduce mortality by 26 percent4.
In addition to these specific goals of deprescribing, medication deintensification can be framed as part of good clinical practice, since all medications are potentially harmful, cost money, and add complexity and the potential for burden. Careful medication review often identifies multiple drug-related problems such as adverse reactions, lack of effectiveness, and burdensome treatment costs, some of which can be successfully addressed through medication withdrawal.