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Deprescribing

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Deprescribing

  • Definitions
  1. Deprescribing
    1. Systematically decrease or discontinue medications which pose greater risk of harm than benefit
    2. Choices are made in the context of the specific patient's goals, values, functional status, Life Expectancy
  • Background
  • Barriers to Deprescribing
  1. Patient reluctance to stop medications (e.g. worry about condition worsening)
  2. Providers with inadequate time to follow the Deprescribing process
  3. Concern for interfering with a specialty provider's care plan
    1. Interphysician communication is critical to this process
  • History
  1. Obtain from Caregivers and Patient
  2. Review records from clinics, hospitalizations, Nursing Homes
  3. Review problem list
  4. Review surgical history
  5. Compile a complete medication list
    1. Prescribed medications (including as needed medications)
    2. Over-the-counter medications
    3. Dietary supplements
    4. Herbals
  • Evaluation
  1. Match each medication to its indication on the problem list
    1. Note medications that do not have an obvious indication
    2. Note medications that have redundant or duplicate activity with other medications for the same indication
    3. Note medications with questionable efficacy in terms of goals, functional status or quality of life
    4. Note medications inappropriate for a patients Life Expectancy or functional status
  2. Consider medication safety
    1. Does the benefit of medication continuation outweigh the risks of adverse effects
    2. Medications to Avoid in Older Adults (STOPP, Beers' Criteria)
    3. Drug-Drug Interactions in the Elderly
    4. Medication Causes of Delirium in the Elderly
    5. Nephrotoxic Drug
  3. Consider Medication Costs
    1. Does the benefit of medication continuation outweigh the excessive cost
    2. Are there less expensive medication alternatives (e.g. formulary)
  • Management
  1. Create a Deprescribing plan with the patient and their Caregivers
  2. Start with medications that are the highest risk with least benefit
  3. Document the overall plan and the decision making for each medication change
  4. Reduce dose, taper or stop one medication at a time
    1. Reassess for improvement versus adverse effects
    2. Schedule phone or clinic visit follow-up at reasonable intervals after each medication change