The deprescribing process

Scott and colleagues have outlined five steps in the deprescribing process: first, find out what medications the patient is taking and the indications; second, consider the overall risk of drug-induced harm; third, assess each medication in terms of eligibility to be discontinued (eg, lack of indication, unacceptable treatment burden, harm outweighs benefit); fourth, prioritise which medications to stop; and finally, implement a plan to stop the medication and monitor the consequences.25 An earlier version of this model has been found to have face validity by hospital clinicians,26 but it is also highly likely to be appropriate to the general practice setting. A review by Reeve et al27 found that, out of 10 published articles describing the deprescribing process or related elements, 4 included all five of these principles. The review also found evidence supporting the different principles, although this was limited in nature. For particular medications, such as selective serotonin reuptake inhibitors, there is a risk of discontinuation reactions. The final stage of the deprescribing process—planning how to stop the medication and arranging follow-up—is likely to reduce this risk.

The Royal Pharmaceutical Society28 outlines four guiding principles for medication optimisation (see figure 1)—referred to in the National Institute for Health and Care Excellence (NICE) Guidelines on Medicines Optimisation.2 These principles are understanding the patient's perspective, views and preferences; assessing the evidence base and cost-effectiveness of treatments; ensuring medicine safety; and establishing medication optimisation as part of routine practice. Although this model is not specifically focused on deprescribing, each of the principles is highly relevant to this process. In particular, patient involvement in decisions to change medications is a key feature.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Summary of the four principles of medicines optimisation.28 Reproduced with permission from the Royal Pharmaceutical Society.

A study in the south of England set out to explore the relationship between shared decision-making and patient satisfaction, adherence and perceived practitioner empathy.29 Prescribing decisions were common, occurring in 79% of consultations, but patients were given treatment options in only 21% of prescribing decisions and the patient's treatment preference was elicited in only 18% of decisions. Prescribing pharmacists were more likely to ask about patient preference than GPs and nurse prescribers. In consultations where more time was spent discussing treatment options, patient-reported satisfaction, adherence and practitioner empathy were rated more highly, although the issue of deprescribing was not specifically studied.

Which patients?

Deprescribing should be routinely considered in the context of preventative medication use in patients with reduced life expectancy,30 and particularly so in palliative cancer care.31 This is especially important given that ≥20% of palliative care patients are in receipt of inappropriate medications,31 and is very pertinent in the general practice setting, with GPs providing end-of-life care to >40% of these patients.32 Increasingly it is recognised that people with non-cancer diseases such as severe chronic obstructive pulmonary disease and heart failure should also be assessed for stepping down treatment and end-of-life considerations.33 People in the care home setting are also likely to be at a point where deprescribing is indicated. Nevertheless, deprescribing is relevant in other clinical situations as well, particularly given that over a third of older general practice patients experience inappropriate prescribing.34 Objective measures of inappropriate prescribing (eg, Beers' criteria35 and the STOPP/START criteria36) are a key primary care patient safety tool,37 and thus an important potential means of identifying individuals in whom deprescribing may be of value. A pragmatic approach of using a straightforward medication count potentially supplemented with indicators of problematic prescribing has been suggested in a King's Fund report.4 There is, however, a need for better approaches to identify situations where deprescribing is appropriate due to issues other than safety or end-of-life care.

Which healthcare professional?

The GPs are ideally positioned to facilitate deprescribing as they have access to the patient's full medical history (including current and drug history, diagnoses and investigations) to help inform medical decisions, and often an established relationship with the patient that imbues trust and supports shared decision-making.38 Decisions to reduce or stop medications are complex, particularly given that patients prescribed multiple medications often have a complex of long-term conditions. As such, GPs who achieve good continuity of care with their patients are perhaps best placed to make deprescribing decisions. Indeed, we have found evidence that there is an association between improved continuity of care and decreased total prescribing burden (Payne RA, unpublished data). In current practice, a formal medication review with a GP is likely to provide the best opportunity to enact decisions around deprescribing, with more dedicated time than is available during the opportunistic circumstances of other appointment types. There is no single agreed approach to the medication review process or the points that should be covered when considering stopping medicines. However, an example of some potential issues that might be considered is shown in box 1. GPs seem readily able to add to medication, but stopping treatments is often not considered at the same time; maybe it would be best if all new medications were only commenced as a trial of therapy and substitution always considered as an alternative to addition. In a US study of primary care physician medication review, discontinuation of medicines was only reported by a fifth of patients.39 Evidence from hospital practice also suggests that recommendations to stop medications are not acted upon,40 and evidence from a community-based older population found that a quarter of medications that had been stopped were reintroduced within the following 12 months.41

GP deprescribing decisions can also be informed by a range of other healthcare professionals, who may have more time than the GP to dedicate to a prescribing review. Primary care nurses often have a central role in managing common long-term conditions in general practice, and Brandt has discussed nurse-led approaches to deprescribing, which are highly relevant to general practice.42 Community pharmacists also have a valuable role with respect to deprescribing. One particular intervention type is medication use reviews (MURs), structured adherence-centred reviews particularly focused on long-term conditions in patients subject to polypharmacy. There is evidence that clinical pharmacist medication reviews can reduce numbers of prescribed drugs,43 and the PINCER trial showed that a pharmacist-led intervention in general practice could reduce hazardous prescribing.44 However, the specific evidence for MURs by community pharmacists is limited.45 There has been a recent call to increase the role of clinical or practice pharmacists to work directly in general practice to address unmet workforce demands,46 and pilot work is being undertaken to explore this in England.47 Finally, although the continuing provision of medication for long-term problems is usually managed by the GP, hospital clinicians (in particular clinical pharmacists and generalist physicians such as geriatricians) can contribute to deprescribing, and hospital-based interventions to identify and stop unnecessary medication for elderly inpatients have indeed been found to be effective.48 Importantly, given that a single patient's management may involve multiple professionals from several healthcare settings, it is essential that the deprescribing process is coordinated and supported by good communication and cooperation.

Guidelines

In the UK, clinical guidance has been published by both Wales and Scotland, detailing approaches to polypharmacy of which medication review is considered central.49 ,50 Both of these identify a number of important clinical areas to focus on, chosen largely on the basis of expert opinion; trial evidence for the effectiveness of the proposed approaches is lacking however. Other priorities have been set by survey work and expert panel opinion undertaken by Farrell and colleagues, which found key classes of medications to include benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants and proton pump inhibitors (PPIs);51 three of these areas are the focus of ongoing work developing evidence-based guidance for deprescribing in these specific therapeutics areas. Lindsay et al52 have also developed and validated a deprescribing guideline specifically for palliative cancer patients.

Treating the patient as central to the medication optimisation process is a key principle outlined by NICE.2 Conklin and colleagues have published a protocol for a study to investigate improving implementation of deprescribing guidelines.53

Trial evidence

Despite the existence of systems that theoretically support deprescribing as well as the development of clinical guidance, trial evidence for deprescribing processes and improved outcome is relatively lacking. An Australian feasibility study by Reeve et al,54 based on the five-step process outlined above, tested a patient-centred intervention to deprescribe PPIs for adults with polypharmacy. The study found that the process was acceptable and could reduce inappropriate PPI use in a small proportion of patients, but there were important barriers to implementation. A Canadian trial of a patient education intervention targeted at patients through community pharmacies demonstrated effectiveness at reducing benzodiazepine use in older adults.55 A systematic review of medication withdrawal found four trials supporting the safe reduction of diuretic therapy (albeit not in heart failure) and some improvements following reduction in psychotropic medication.56 Antipsychotic withdrawal has also been found to be safe in the majority of people with dementia.57 Despite hypertension being the most prevalent long-term condition in older people, randomised trials of antihypertensive withdrawal are lacking, although prospective observational studies suggest many patients remain normotensive.56

Patient and carer views

Certainly, overall, patients are supportive of the idea of deprescribing. The term deprescribing may not be acceptable to some patients, however, who might associate it with money saving.58 A survey of Australian care homes found 40% of residents expressed a wish to reduce their medications with over three-quarters willing to do so if deemed possible by their doctor.59 Patients taking nine or more medications were more likely to report medication side effects but no more likely to want to reduce their medications compared with those taking fewer medications. A further survey of older ambulatory care adults using the same scale—the ‘Patient's Attitudes to Deprescribing Questionnaire’—found that >90% were willing to stop one or more medications.38 Again willingness to stop medications was not found to be associated with the number of regular medications prescribed; however, the study was inadequately powered with only 100 study participants. A systematic review found that patient-reported barriers to deprescribing included disagreement over the appropriateness of stopping medication (eg, views that the medication was necessary to prevent future illness); lack of a process to stop medication (eg, the GP lacking time or knowledge to safely stop medication) and fear of stopping medications (eg, fear of withdrawal effects, fear of a medical condition returning or previous negative experiences of stopping medications).60 Enablers to deprescribing were agreement that it was appropriate to stop the medication, a system to stop or taper down the medication and a dislike of taking medications (eg, the inconvenience of having to take complex medication regimens and concerns that medications were ‘unnatural’).

Clinician views

Anderson et al61 conducted a systematic review and thematic synthesis of qualitative studies that explored prescribers' perceived barriers and enablers to minimising potentially inappropriate medications for adults with long-term conditions. Twenty-one studies were included, and most focused on the views of primary healthcare physicians towards managing elderly patients. Factors that influenced decisions of whether or not to deprescribe were grouped as being intrinsic to the prescriber (eg, their beliefs, attitudes, knowledge, skills and behaviour) or extrinsic to the prescriber (eg, the patient, work setting, health system and cultural factors). Clinician inertia, whereby the clinician is aware of the potential harmful effects of medications but chooses not to act on this knowledge and stop the medication, was key. Reasons for this included not wanting to generate more work (eg, having to monitor the effects of stopping medications or overcoming logistical issues such as making changes to dosette boxes); avoiding conflict with other healthcare professionals who may have started the medication; concerns about a relapse of symptoms; and beliefs that, by continuing the medications, the patient was unlikely to come to harm.

A substudy of the ECSTATIC trial investigated attitudes to stopping preventive cardiovascular medication.62 GPs reported that their decision to stop unnecessary medication was influenced by their perception that specialists would disapprove of them stopping medications. A study in New Zealand investigated GPs' views on deprescribing in multimorbid elderly patients.63 Considerable variation in opinions on deprescribing was observed between GPs, and the authors proposed better guidelines for stopping medicines in order to reduce such variation.

A survey of physicians specialising in care of the elderly attitudes to deprescribing found that limited life expectancy, cognitive impairment and pill burden were important drivers to deprescribing.64

In a recent South Australian study, GPs ranked evidence for deprescribing and patient/family communication as the most important factors to consider when considering stopping medications. This differed from other healthcare professionals, with nurses prioritising doctors' receptivity to deprescribing and patient advocacy, and pharmacists prioritising clinical appropriateness and identifying patients' goals.65

Special groups: care home residents, palliative care patients and the very elderly

There are a number of groups for whom deprescribing may be particularly relevant. Tailored approaches to managing the process specific to these groups may need to be considered.

A study in Australia sought to explore the views of care home residents, relatives and care professionals towards polypharmacy and deprescribing.66 Care home residents reported that taking lots of medication was burdensome but they lacked understanding of what the medications were for and of potential harms caused by the medication. They trusted their GP and were willing to accept changes, including stopping medications, if they were suggested by their GP. Barriers to deprescribing reported by GPs included a lack of time, poor medical record keeping for care home residents, limited training of care home workers and difficulties with collaborating with care home workers and pharmacists.

A qualitative study in the USA to explore palliative care patients’, carers’ and healthcare professionals’ views on stopping unnecessary medications, such as statins, found that patients were accepting of the concept of stopping preventative medications once they had come to terms with the fact that their illness was life-limiting.67 The authors concluded that it was important to explore patients’ expectations of their illness and treatment, and to time discussions about stopping medications appropriately.

A study of Dutch GPs’ views on deprescribing in the very elderly found that GPs broadly categorised medications into ‘symptomatic medication’ and ‘preventative medication’.68 Deciding to deprescribe preventative medication was seen as more difficult for GPs because there was a lack of guidance about the risk/benefit ratio. GPs believed that patients did not have a problem taking multiple medications and were worried that by stopping medication patients would feel that they were giving up on them. They were reluctant to discuss issues about approaching the end of life with patients. Other barriers to deprescribing included having to comply with guidelines to increase medications.