Discontinuing medications: Proceed carefully
Physicians are often reluctant to discontinue chronic medications in older patients—even in those with advanced disease who are not likely to benefit from treatment. Focus groups have identified a number of reasons for their hesitation, including:
- the assumption that patients have no problem taking large numbers of drugs
- the fear that patients may misinterpret a plan to discontinue medications as evidence that the physician is giving up on them
- the belief that physicians must comply with practice guidelines that recommend multiple drug treatments
- concern that proposing discontinuation of medications often leads to a discussion of life expectancy and end-of-life care.28
Physicians may also fear that discontinuation of certain drugs will increase the risk of adverse outcomes. More than 30 studies have evaluated discontinuation of chronic medications in older adults, however, and found that drugs as diverse as antihypertensives, antipsychotics, benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs) can often be discontinued without adverse outcomes. In many cases, improvement in patient function results.29 Medications that present the most difficulty are those that patients often become physically or psychologically dependent on, such as benzodiazepines, guaifenesin, proton-pump inhibitors, nonsteroidal anti-inflammatory drugs, and SSRIs. Some (eg, benzodiazepines, SSRIs) require a gradual reduction; for others, no taper is required
(TABLE 4).30-37
TABLE 4
Recommendations for discontinuing hard-to-stop drugs
| Medication or drug class | Discontinuation regimen | Comments |
|---|---|---|
| Benzodiazepines30 | Taper dose by 25% q 2 wk | No withdrawal symptoms reported with this taper regimen. Subtle cognitive improvement noted over a period of months |
| Guaifenesin31 | Can be discontinued without tapering if not combined with opioids or other medications. Elimination half-life is approximately 1 hour | Guaifenesin is often marketed as a combination product with opioids; such combination products require tapering |
| PPIs32-34 | Decrease dose by 50% q 2 wk; supplement with H2 blocker if needed, but tapering of H2 blocker may be required | Abrupt discontinuation after long-term use causes rebound gastric acid hypersecretion and lowers rate of success. Higher success rates with taper regimen and in patients who do not have documented GERD |
| NSAIDs35 | No taper required | Short-term use (<3 mo) acceptable for patients with no contraindications |
| SSRIs36,37 | Gradual reduction in dose over 6-8 wk | Highest rate of success in patients without a clear diagnosis of depression |
| GERD, gastroesophageal reflux disease; NSAIDs, nonsteroidal anti-inflammatory drugs; PPIs, proton-pump inhibitors; SSRIs, selective serotonin reuptake inhibitors. | ||
CASE You trim down Mrs. R’s regimen by discontinuing each of the 8 drugs, one at a time, and carefully monitor the patient during the withdrawal period. Because she had been taking alprazolam daily, the dose is tapered slowly to avoid withdrawal. Omeprazole also requires a gradual taper to avoid rebound hyperacidity.3
After confirming that Mrs. R has heart failure and COPD, you identify 2 medications that should be added to her drug regimen—an ACE inhibitor for heart failure and an inhaled anticholinergic for COPD.
Going from 16 medications to 10 saves money, decreases the likelihood of adverse events and drug-drug interactions, and helps with adherence. Mrs. R’s new drug regimen is expected to lead to improvements in memory and overall quality of life, as well.
CORRESPONDENCE
Barry D. Weiss, MD, Department of Family and Community Medicine, University of Arizona College of Medicine, Tucson, AZ 85724; bdweiss@email.arizona.edu