Deprescribing

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

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
1. Interphysician communication is critical to this process

Obtain from Caregivers and Patient
Review records from clinics, hospitalizations, Nursing Homes
Review problem list
Review surgical history
Compile a complete medication list
1. Prescribed medications (including as needed medications)
2. Over-the-counter medications
3. Dietary supplements
4. Herbals

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
Consider Medication Safety
1. Does the benefit of medication continuation outweigh the risks of adverse effects
  1. PPIs are often continued for years despite symptom free (risk of C. difficile, Vitamin Deficiency)
  2. Statins and Bisphosphonates may add little benefit at the end of life with low Life Expectancy
  3. Loosening diabetes target Blood Sugars (e.g. Hemoglobin A1C to <8%) lowers risk of Hypoglycemia
2. Medications to Avoid in Older Adults (STOPP, Beers' Criteria)
  1. Muscle Relaxants have low efficacy, high Fall Risk; apnea risk when combined with Opioids
3. Drug-Drug Interactions in the Elderly
4. Medication Causes of Delirium in the Elderly
5. Nephrotoxic Drug
Consider Medication Costs
1. Does the benefit of medication continuation outweigh the excessive cost
2. Are there less expensive medication alternatives (e.g. formulary)

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
1. Give clear written and verbal instructions to the patient and their care giver
Reduce dose, taper or stop one medication at a time
1. Taper Benzodiazepines or Opioids
2. Step down therapy from Proton Pump Inhibitors (PPIs) to H2 Antagonists
3. Reassess for improvement versus adverse effects
4. Schedule phone or clinic visit follow-up at reasonable intervals after each medication change