Examples of deprescribing

Every drug review for older people should consider which medicines to continue, but equally important, which medicines can be discontinued. As we age, the balance between potential benefits and potential risks of medications often shifts towards more harm. For example, antidepressants are commonly prescribed in general, but in the older person, they carry specific potential harms. Further, there is data indicating that a substantial proportion of users have no evidence-based indications to continue antidepressants and could be candidates to try stopping treatment...

BACKGROUND: Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. OBJECTIVE: To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. DESIGN: Qualitative study using semi-structured interviews...

An article published in the JAMA Network in the final days of 2020 titled "Just Do It - Everyone Should Follow the Guidelines," indicates that not everyone is receiving the message about polypharmacy. Though not a paper about medications, the "just do it" article provides an example of the prevailing culture in healthcare - guidelines become rules, and, if you assess, then you will likely prescribe. The prescriber soothes by prescribing, and the patient bears the burden.

There is no drug therapy without risk for toxicity. The patient must tolerate some toxic or idiosyncratic adverse events (e. g. hand foot syndrome). After life threatening adverse effects, one needs to screen (hyperkalemia). The sick-day-rule should be communicated with the informed patient as for example stopping SGLT2-inhibitors (loss of appetite, hypotension). The list of prescriptions should regularly criticized for dangerous or superfluous medicines (deprescribing).

Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation...

UNLABELLED: CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020...

In end-of-life care, deprescribing practices may vary considerably from one practitioner to the next, although most published frameworks for evaluating medication appropriateness in advanced illness consider three key principles (1) patient and caregiver goals, (2) remaining life expectancy (LE), and (3) medication time to benefit (TTB). The objective of this article is to provide clinicians with a structured, consistent approach for deprescribing that does not replace clinical judgment or the preferences of patients and their families but enhances it through clinical data...

The COVID-19 pandemic has changed psychopharmacological prescribing and management of patients around the world. Social distancing requirements led to a transition from face-to-face patient visits to telepsychiatry. Relaxed federal reimbursement policies during the COVID-19 pandemic expanded patient awareness and access to virtual care. For many psychiatric advanced practice RNs (APRNs), the transition to telepsychiatry was intended as a temporary solution until it is possible to return to in-person patient care...

We present a novel view of transitions from the lens of patient ergonomics (the "science of patient work"), which posits that patients and other non-professionals perform effortful work towards health-related goals. In patient work transitions, patients experience changes in, for example, health, task demands, work capacity, roles and responsibilities, knowledge and skills, routines, needs and technologies. Medication transitions are a particularly vulnerable type of patient work transitions. We describe two cases of medication transitions-new medications and medication deprescribing-in which the patient work lens reveals many accompanying changes, vulnerabilities, and opportunities for human factors and ergonomics...

PURPOSE OF REVIEW: This study will provide a narrative review of the history of the clinical use of low-carbohydrate diets and give a practical example of how to implement a low-carbohydrate diet, with an emphasis on deprescribing medications. RECENT FINDINGS: Low-carbohydrate diets have been used since the late 19th century to treat obesity and type 2 diabetes mellitus (T2DM). Recently, clinical research has validated the use of low-carbohydrate diets for individuals affected by obesity and T2DM, and these diets are included in several national clinical guidelines...

BACKGROUND: Potentially inappropriate medication (PIM) is considered to have potentially more harmful than beneficial health effects in elderly patients. A German example for a PIM list is the PRISCUS list that has been available since 2010. PIMs are associated with an increased risk of hospitalisation and adverse health outcomes. Furthermore, drug-drug interactions (DDI) may pose additional risks to patients. It is not yet clear how numbers of PIM and DDI can be reduced in community-dwelling seniors in primary care; nor is it clear whether patients would benefit from such deprescribing...

BACKGROUND: Medications endorsed by clinical practice guidelines, such as cardiovascular medications, could still have risks that outweigh potential benefits, and could thus warrant deprescribing. OBJECTIVES: The objective of this study was to develop a framework of facilitators and barriers specific to deprescribing cardiovascular medications in the setting of uncertain benefit. Given the frequent use of β-blockers in heart failure with preserved ejection fraction, and its uncertain benefits with potential for harm, we used this scenario as an example case for a cardiovascular medication that may be reasonable to deprescribe...

BACKGROUND: People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use. OBJECTIVE: To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions. DESIGN: Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment...

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process...

BACKGROUND: At a recent World Café Workshop on future deprescribing priorities, Canadian researchers identified that, in addition to implementation evaluation and economic analyses, high quality clinical trials require meaningful patient engagement. OBJECTIVES: The aim was to develop a deprescribing intervention for collaborative primary healthcare clinics and long-term care facilities that have pharmacists integrated in these settings. This manuscript aims to provide a summary of the experience with engaging patients in the development of the deprescribing framework...

BACKGROUND: GPs are confronted with therapeutic dilemmas in treating patients with multimorbidity and/or polypharmacy when unfavourable medication risk-benefit ratios (RBRs) conflict with patients' demands. AIM: To understand GPs' attitudes about prescribing and/or deprescribing medicines for patients with multimorbidity and/or polypharmacy, and factors associated with their decisions. DESIGN AND SETTING: Cross-sectional survey in 2016 among a national panel of 1266 randomly selected GPs in private practice in France...

Medication management is becoming increasingly challenging for older people, and there is limited evidence to guide medication prescribing and administration for people with multimorbidity, frailty, or at the end of life. Currently, there is a lack of clear research priorities in the field of geriatric pharmacotherapy. To address this issue, international experts from 5 research groups in geriatric pharmacotherapy and pharmacoepidemiology research were invited to attend the inaugural Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network workshop...

As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications. Areas covered: This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship...

It is widely acknowledged that patients-particularly those late in life-are frequently exposed to the harms of medication. To minimize these harms, several frameworks have been developed by which prescribing can be optimized. In the context of diminishing life expectancy, these frameworks can be used to reduce medications that are no longer necessary, but appear to fall short of actual guidelines that incorporate a consideration of stopping medications. In this commentary, we present recommendations that could be incorporated into prescribing processes for all healthcare professionals and, ultimately, used to support the rationalization or deprescribing of medication in diminished life expectancy...