Evidence-Based Deprescribing: Reversing the Tide of Potentially Inappropriate Polypharmacy

A challenge for all involved in deprescribing is gaining agreement on what are the most important factors that determine when, how, and in whom deprescribing should be conducted. Recent qualitative studies suggest that doctors, pharmacists, nursing staff, and patients and their families, while in broad agreement that deprescribing is worthwhile, often differ in their perspectives on what takes priority in selecting medicines for deprescribing in individual patients, and how it should be done and by whom [76,77].

Strategies That May Facilitate Deprescribing

While deprescribing presents some challenges, there are several strategies that can facilitate it at both the level of individual clinical encounters and at the level of whole populations and systems of care.

Individual Clinical Encounters

Within individual clinician–patient encounters, patients should be empowered to ask their doctors and pharmacists the following questions:

• What are my treatment options (including non-medicine options) for my condition?
• What are the possible benefits and harms of each medicine?
• What might be reasonable grounds for stopping a medicine?

In turn, doctors and pharmacists should ask in a nonjudgmental fashion, at every encounter, whether patients are experiencing any side effects, administration and monitoring problems, or other barriers to adherence associated with any of their medicines.

The issue of deprescribing should be framed as an attempt to alleviate symptoms (of drug toxicity), improve quality of life (from drug-induced disability), and lessen the risk of morbid events (especially ADEs) in the future. Compelling evidence that identifies circumstances in which medicines can be safely withdrawn while reducing the risk of ADEs needs to be emphasized. Specialists must play a sentinel leadership role in advising and authorizing other health professionals to deprescribe in situations where benefits of medications they have prescribed are no longer outweighed by the harms [60,78].

In language they can understand, patients should be informed of the benefit–harm trade-offs specific to them of continuing or discontinuing a particular medicine, as far as these can be specified. Patients often overestimate the benefits and underestimate the harms of treatments [79]. Providing such personalised information can substantially alter perceptions of risk and change attitudes towards discontinuation [80]. Eliciting patients’ beliefs about the necessity for each individual medicine and spending time, using an empathic manner, to dispel or qualify those at odds with evidence and clinical judgement renders deprescribing more acceptable to patients.

In estimating treatment benefit–harm trade-offs in individual patients, disease risk prediction tools (http://www.medal.org/), evidence tables [81,82], and decision aids are increasingly available. Prognostication tools (http://eprognosis.ucsf.edu) combined with trial-based time-to-event data can be used to determine if medicine-specific time until benefit exceeds remaining life span.

Deprescribing is best performed by reducing medicines one at a time over several encounters with the same overseeing generalist clinician with whom patients have established a trusting and collaborative relationship. This provides repeated opportunities to discuss and assuage any fears of discontinuing a medicine, and to adjust the deprescribing plan according to changes in clinical circumstances and revised treatment goals. Practice-based pharmacists can review patients’ medicine lists and apply screening criteria to identify medicines more likely to be unnecessary or harmful, which then helps initiate and guide deprescribing. Integrating a structured deprescribing protocol—and reminders to use it—into electronic health records, and providing decision support and data collection for future reference, reduce the cognitive burden on prescribers [83]. Practical guidance in how to safely wean and cease particular classes of medicines in older people can be accessed from various sources [84,85]. Seeking input from clinical pharmacologists, pharmacists, nurses, and other salient care providers on a case-by-case basis in the form of interactive case conferences provides support, seeks consensus, and shares the risk and responsibility for deprescribing recommendations [86].