DEPRESCRIBING

Definition

• Planned and supervised process of dose reduction or stopping medication that may no longer benefit the patient or cause more harm than good
• Benefits can include improved quality of life and reduced pill burden for patient

Patient groups

• Patient groups that may benefit:
• end of life (prognosis of ≤3 months)
• multi-morbidity (presence of ≥2 long term health conditions)
• frail, elderly patients
• declining renal or hepatic function

Who actions?

• Only a prescriber undertakes deprescribing
• prescribers are accountable for the effects of deprescribing and prescribing a medication
• involve patients in decisions regarding the initiation and/or cessation of medicines including potential side effects and intended outcomes of treatment

• For all medication consider the following
• what are the benefits of the medication?
• are the expected benefits important to the patient’s goals?
• is the benefit likely to be realised given the short life expectancy?
• is the medication’s target symptom or disease still applicable?
• does the medication manage symptoms or prevent on-going progressive disease?

• Take a comprehensive medication history and check adherence
• if a medication is never or rarely taken this makes stopping easier
• Identify potentially inappropriate medications and whether these medications can be stopped
• Plan withdrawal regimen
• can the medication be stopped abruptly, or does it need to be tapered over time?
• in general medications should be reduced or stopped one at a time. However, in last days of life it can be appropriate to stop multiple medications abruptly
• Document in medical notes the rationale for deprescribing and discussions undertaken with patient or their carer
• Check for benefit or harm after each medication has been reduced or stopped
• If a medication needs to continue with patient unable to take an oral medication, consider an alternative route such as transdermal or subcutaneous

Common medications to consider deprescribing

• Antiplatelet agents/anticoagulants
• Statins
• NSAIDS (especially in combination with a diuretic)
• Cardiovascular drugs (especially ACEI and in patients with renal impairment)
• Hypoglycaemic agents
• Bisphosphonates

Helpful tool

• STOPP/START tool: identifies high risk problems in prescribing for older people, both in terms of reducing medicine burden and adding in potentially beneficial therapy