II. Definitions
- Deprescribing
- Systematically decrease or discontinue medications which pose greater risk of harm than benefit
- Choices are made in the context of the specific patient's goals, values, functional status, Life Expectancy
III. Background: Barriers to Deprescribing
- Patient reluctance to stop medications (e.g. worry about condition worsening)
- Providers with inadequate time to follow the Deprescribing process
- Concern for interfering with a specialty provider's care plan
- Interphysician communication is critical to this process
IV. History
- Obtain from Caregivers and Patient
- Review records from clinics, hospitalizations, Nursing Homes
- Review problem list
- Review surgical history
- Compile a complete medication list
- Prescribed medications (including as needed medications)
- Over-the-counter medications
- Dietary supplements
- Herbals
V. Evaluation
- Match each medication to its indication on the problem list
- Note medications that do not have an obvious indication
- Note medications that have redundant or duplicate activity with other medications for the same indication
- Note medications with questionable efficacy in terms of goals, functional status or quality of life
- Note medications inappropriate for a patients Life Expectancy or functional status
- Consider Medication Safety
- Does the benefit of medication continuation outweigh the risks of adverse effects
- PPIs are often continued for years despite symptom free (risk of C. difficile, Vitamin Deficiency)
- Statins and Bisphosphonates may add little benefit at the end of life with low Life Expectancy
- Loosening diabetes target Blood Sugars (e.g. Hemoglobin A1C to <8%) lowers risk of Hypoglycemia
- Medications to Avoid in Older Adults (STOPP, Beers' Criteria)
- Drug-Drug Interactions in the Elderly
- Medication Causes of Delirium in the Elderly
- Nephrotoxic Drug
- Does the benefit of medication continuation outweigh the risks of adverse effects
- Consider Medication Costs
- Does the benefit of medication continuation outweigh the excessive cost
- Are there less expensive medication alternatives (e.g. formulary)
VI. Management
- Create a Deprescribing plan with the patient and their Caregivers
- Start with medications that are the highest risk with least benefit
- Document the overall plan and the decision making for each medication change
- Give clear written and verbal instructions to the patient and their care giver
- Reduce dose, taper or stop one medication at a time
- Taper Benzodiazepines or Opioids
- Step down therapy from Proton Pump Inhibitors (PPIs) to H2 Antagonists
- Reassess for improvement versus adverse effects
- Schedule phone or clinic visit follow-up at reasonable intervals after each medication change
VII. Resources
- Medication Appropriateness Index (GlobalRPH)
- GoodRx
- MedStopper
VIII. References
- Halli-Tierney (2019) Am Fam Physician 100(1): 32-8 [PubMed]
- (2024) Presc Lett 31(7): 41