Deprescribing: A Clinical Challenge
Resources Abound to Guide Physicians Around This Increasingly Essential Skill
By Katherine O’Brien
In a health care system geared toward starting medications rather than reducing or stopping them, polypharmacy — the concurrent use of five or more medications by a patient — is a clinical challenge, according to Dr. Barbara Farrell, co-founder of the Canadian Deprescribing Network.
“The constant refrain that I have heard from physicians when providing polypharmacy education is the guidelines don’t tell me when to stop a drug, they only tell you when to start a drug,” she said during Choosing Wisely Canada’s “How to Deprescribe Wisely” presentation in late May.
Deprescribing — the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit — is generally safe, especially when it’s well monitored for adverse drug withdrawal events, said Dr. Farrell, a pharmacist with the Bruyère Geriatric Day Hospital and a Senior Investigator with the Bruyère Research Institute in Ottawa.
Knowing how to safely reduce inappropriate medications may be an increasingly essential skill for physicians — nearly one-half of older adults take five or more drugs, and about one in four take at least 10. Studies have shown that patients taking five or more medications often find it difficult to adhere to complex medication regimens. Another sobering statistic: up to 20 percent of these prescriptions are potentially inappropriate, as mentioned in “Deprescribing Is an Essential Part of Good Prescribing,” co-written by Dr. Farrell and Dr. Dee Mangin. In the presentation, Dr. Farrell pointed out that deprescribing polypharmacy can lead to a reduction in mortality. A meta-analysis published in 2019 found in its review of 41 randomized clinical studies, deprescribing interventions significantly reduced the number of nursing home residents with potentially inappropriate medications by 59 percent. In subgroup analysis, deprescribing interventions reduced all-cause mortality by 26 percent as well as the number of falls by 24 percent.
Still, even in cases when the potential harm of continuing a medication would likely outweigh the benefits, implementing deprescribing can be challenging as many questions arise, she said. Typical concerns include: “What’s going to happen if we try to stop? And will there be withdrawal? [If so,] how severe will it be? When will that happen? How do I handle it?”
Luckily, deprescribing has become easier in recent years, thanks to an increasing number of tools, said Dr. Farrell, who, along with Dr. Cara Tannenbaum and their research teams, developed the deprescribing.org website. In fact, researchers had a “light bulb moment” more than 10 years ago when they realized they could help walk physicians through the steps of safe deprescribing by developing guidelines.
Currently, the site contains five deprescribing guideline algorithms, which target proton pump inhibitors (PPIs), antipsychotics, antihyperglycemics, hypnotic-sedatives, and cholinesterase inhibitors and memantine. (The algorithms, as well as links to the guideline publications, can also be found on the deprescribing.org app.) Another resource is Choosing Wisely Canada’s toolkits on how to reduce and discontinue benzodiazepines, PPIs and antipsychotics.
Medications like antibiotics, opioids, antimicrobials, sedative-hypnotics and antipsychotics are also targeted in recommended guidelines from various medical organizations.
The guidelines from the Canadian Society of Hospital Pharmacists also advise avoiding medications for long-term risk reduction, if life expectancy is short.
Several resources can help physicians identify medications that could potentially be reduced or stopped — the first step in the five-step deprescribing process as outlined in the “Deprescribing Is an Essential Part of Good Prescribing” article. These tools include the American Geriatrics Society Beers Criteria, Medstopper and the STOPP/START Criteria for potentially inappropriate prescribing in older people. Another tool, the Anticholinergic Burden Calculator, allows doctors to find suggestions for alternative medications that would reduce anticholinergic burden, said Dr. Farrell. (The other four steps in the deprescribing process are: 2. determining if the medication can be reduced/stopped; 3. planning the tapering; 4. monitoring and supporting the patient; and 5. documenting outcomes.)
At the Bruyère Geriatric Day Hospital, practitioners include a rationale on the prescription so everyone — the doctor, the pharmacist and the family — is kept in the loop, and patients are seen once or twice a week so they can be closely monitored, said Dr. Farrell.
One positive patient experience Dr. Farrell shared at the presentation was that of a 76-year-old patient with severe cognitive impairment, whose cognition dramatically improved after she stopped taking doxepin. Four weeks after she stopped taking the drug — she had been on a very high dose (250 mg daily) for years — her score on the Montreal Cognitive Assessment (MoCA) increased from 19 to 25. “At the end of that discussion, as I was talking to this patient, she pulled out her phone and ordered an Uber — which I can’t even do,” said Dr. Farrell.
Step 1: Identify medications that could potentially be reduced or stopped
Step 2: Determine if the medication can be reduced/stopped
Step 3: Plan the tapering
Step 4: Monitor and support the patient
Step 5: Document outcomes
In our Doc Talk column, we discuss some strategies to help making deprescribing easier.