Introduction
Why Deprescribe?
The Course of the Practice
Future Directions
References
The term ‘deprescribing” was first used almost two decades ago, in 2003, but more time elapsed before suggested guidelines for this practice were published. This term refers to the withdrawal, reduction in dosage, or replacement, of medications for patients following a review of all current medications.
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Why Deprescribe?
Polypharmacy, or the prescription of multiple medications, increases the risk of adverse drug reactions twofold, from 6% among patients on one or two medications to 13% among those on five drugs. Secondly, especially among older patients, this increases the risk of non-compliance and drug interactions.
This can be avoided by discussing treatment plans with patients, including reviewing all existing medicine lists and the potential side effects. However, it may take more time than many physicians have. The answer is not underprescribing or refusing to prescribe necessary medications simply because the patient is already taking many drugs. This, sadly, may occur among patients with multiple medical conditions, which dictates the need for multiple medications.
The proper alternative is to review the indications for each medication on the patient’s list, ensure that all changes are noted over time, and reassess the appropriateness of each in the current health and care goal context. For instance, preventive medications may not be clearly beneficial in very elderly and frail patients.
This could be improved by using universal treatment outcomes and targets rather than goals specific to each disease. This would help focus on symptomatic improvement, increase the lifespan, and a greater degree of independence and functionality.
The Course of the Practice
Michael Woodward first described this in his article in 2003, which appeared in the Journal of Pharmacy Practice and Research. Since then, several articles have traced the high incidence of polypharmacy and the lack of guidelines in prescribing for people with multiple underlying conditions. Due to this, even though the cessation of medicines should ideally be part of the prescribing process, it is currently being treated as a separate entity.
As late as 2006, medications prescribed to a single individual were on the increase, especially cardiovascular, psychotropic and gastrointestinal medications. Even among these, those with primarily preventive goals showed the highest slope of increase, such as medications to prevent osteoporosis and lipid-lowering agents.
This could be due to a more guideline-based practice of medicine, with greater identification and management of chronic disease risk factors. However, the benefits of this markedly increased number of medications in the elderly, especially since clinical trials in this age group do not back them. Complex treatment regimes become difficult to follow and expensive.
Moreover, the steep increase in prescriptions may compromise patient safety and lead to iatrogenic harm, especially since many interactions are currently unknown but could be potentially harmful. Another risk is the so-called prescribing cascade, where one medication causes adverse effects that are treated by prescribing another, which in turn leads to another, and so on.
A 2014 study showed dramatic increases in prescribing preventives such as those intended to prevent osteoporosis and those that reduced blood cholesterol levels, especially in female patients older than 85. During the study period, there were almost three times more patients of advanced age who were taking more than ten medications.
Other terms such as rationalization or de-escalation of treatment have been used to describe what is basically the same concept earlier, but the term ‘deprescribing’ carries more clarity. Currently, many studies are being carried out on this practice, but the results will be difficult to compare in a standardized manner unless the term is described definitively.
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Future Directions
Most earlier trials of deprescribing deal with the withdrawal of medications rather than the outcomes following this step. Functional outcomes such as falls and hospitalizations are difficult to assess without long-term studies, and the apparent lack of difference in such outcomes despite deprescribing is thus likely to be without significance.
One major systematic review found that most studies examined the tolerability of deprescribing but without evaluating the clinical benefit. However, most studies concluded that the patient did not suffer any harm from these withdrawals of non-required drugs, while a few showed a lower risk of falls after deprescribing.
Others have shown that less than one in five patients eventually required to be put back on the discontinued medication, while the mortality rate at one year was significantly lower in the deprescribed cohorts. The difficulty with applying such evidence clinically lies in the absence of detail on how such drug withdrawal was carried out and how monitoring was performed subsequently.
As of now, most older adults would agree to have their daily medications reduced, despite their apprehension that the medicines they are taking are required. Future studies that contain such specific and systematic details will be required to build an evidence base on deprescribing.
References:
Further Reading
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