In a recent blog, we looked at various definitions for polypharmacy and then summarized the risks and benefits of polypharmacy. In the section on benefits, we discussed times when polypharmacy — most frequently defined as the routine use of five or more medications — is appropriate and emphasized that any undertaking to reduce the usage of medications by patients should not focus on the number of medications but rather achieving optimal polypharmacy management. That's where deprescribing comes in.
Deprescribing is a relatively new term concerning medication management. An article in the Journal of the American College of Cardiology defines deprescribing as follows: "Deprescribing, a top priority in patient safety, is the process of medication withdrawal or dose reduction under healthcare supervision to reduce unnecessary or potentially harmful medication use with the goal of improving outcomes."
An UpToDate column specifically ties deprescribing to polypharmacy when it states, "The term 'deprescribing' refers to a process of medication withdrawal, supervised by a healthcare professional, with the goal of managing polypharmacy and improving outcomes."
Both definitions describe clinical deprescribing as a "process," and this is important: Deprescribing requires those healthcare professionals involved in working to attain optimal polypharmacy to understand and, when appropriate, follow guidelines to best ensure patient safety and achieve desired results (i.e., improved outcomes).
A number of evidence-based deprescribing guidelines have been developed to date. We expect that more will be published as researchers and medication experts gain new and improved understanding of opportunities to improve management of various medication classes and safely reduce reliance upon different medications.
Bruyère Deprescribing Guidelines
We'll begin our discussion about clinical deprescribing guidelines by looking at five regularly cited guidelines developed by the Bruyère Research Institute Deprescribing Guidelines Research Team and collaborators. The guidelines, along with decision-support algorithms and some other resources, are available on the Bruyère's Deprescribing.org website. The following clinical guidelines are listed in alphabetical order by medication class.
1. Antihyperglycemic Deprescribing Guideline
Antihyperglycemic agents are designed to lower blood glucose levels and are commonly used in the treatment of diabetes. According to Deprescribing.org, safe reduction of an antihyperglycemic can be accomplished by patients by doing the following:
"First, work with your healthcare provider to choose appropriate blood sugar and A1C targets for your age and state of health. For example, blood sugars less than 12mmol/L and A1C less than 8.5% may be appropriate for an older, frailer person with many other medical conditions.
"Together, develop a plan for medication changes. This might involve reducing a dose, changing to a safer medication, or stopping a medication altogether. Such changes could occur every 1-2 weeks, always under the supervision of your healthcare provider."
When making a change, patients are advised to check blood sugar daily for 1-2 weeks after each change. A longer monitoring time — up to 12 weeks — may be required based upon the type of medication a patient is taking.
Credit: Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, et al. Deprescribing antihyperglycemic agents in older persons. Evidence-based clinical practice guideline. Can Fam Physician 2017;63:832-43 (Eng), e452-65 (Fr).
2. Antipsychotic Deprescribing Guideline
Antipsychotics, also referred to as neuroleptics, are a class of drugs used to treat serious psychiatric disorders. These medications are particularly useful for treating schizophrenia, bipolar disorder, and mania with psychosis, among other disorders.
According to Deprescribing.org, safe reduction of an antipsychotic should be accomplished by doing the following:
"People who have been taking an antipsychotic for behavioral and psychological symptoms of dementia (BPSD) for at least three months, or people who have been taking an antipsychotic for insomnia, should talk to their healthcare provider about whether stopping the antipsychotic is the right choice for them. …
"For BPSD symptoms, slowly reducing the dose of an antipsychotic over several weeks is recommended. This allows healthcare providers to carefully monitor for any return of symptoms. If used in low doses for insomnia, antipsychotics can be stopped completely without first reducing the dose."
When reducing an antipsychotic used for BPSD, patients are advised to check for and report signs of psychosis, aggression, agitation, delusions, and hallucinations. Reduction of an antipsychotic used for insomnia is not typically associated with withdrawal reactions.
Credit: Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Can Fam Physician 2018;64:17-27 (Eng), e1-e12 (Fr).
3. Benzodiazepine Receptor Agonist Deprescribing Guideline
Benzodiazepine receptor agonists (BZRAs) include benzodiazepines and drugs such as zolpidem (Ambien) that are used to treat insomnia and anxiety. American Family Physician summarizes the key points for deprescribing BZRAs as follows:
- A slow taper of BZRAs is recommended in patients 18-64 years of age who use these most days of the week for more than four weeks.
- Patients 65 years and older taking a BZRA for any duration should be recommended to taper off slowly.
- A slow taper with a 25% dose reduction every two weeks and medication-free days at the end of the taper is suggested.
When reducing a BZRA, patients may experience difficulty sleeping and/or symptoms of withdrawal, usually in the first few days and weeks following the reduction.
4. Cholinesterase Inhibitors and Memantine Deprescribing Guideline
Cholinesterase inhibitors (Aricept, Exelon, Razadyne) and memantine (Namenda) are FDA-approved drugs used to treat dementia and the cognitive symptoms of Alzheimer's disease.
A Medscape interview with Dr. Emily Reeve, lead author of the clinical deprescribing guideline for cholinesterase inhibitors (ChEIs) and memantine provided on Deprescribing.org, summarizes the guideline as follows: "The guideline stresses that deprescribing should begin as a trial discontinuation, with close periodic monitoring (e.g., every four weeks). The dose of ChEI/memantine should be tapered by halving the dose or by stepping down through available dose formulations every four weeks to the lowest available dose, followed by discontinuation."
Dr. Reeve told Medscape that if patients exhibit clear worsening of symptoms at any time up to three months after dose reduction or cessation, and after healthcare professionals have excluded other causes, then medication can be restarted. She noted that there did not appear to be any long-term harm associated with a temporary dose reduction or stopping based upon existing — albeit limited — evidence.
5. Proton Pump Inhibitors Deprescribing Guideline
The final Deprescribing.org evidence-based clinical deprescribing guideline concerns proton pump inhibitors (PPIs). PPIs reduce the amount of stomach acid made by glands in the lining of the stomach and are used to relieve symptoms of acid reflux, or gastroesophageal reflux disease (GERD); treat a duodenal or gastric ulcer; and treat damage to the lower esophagus caused by acid reflux.
According to Deprescribing.org, safe reduction of PPIs should be accomplished by doing the following:
"People over the age of 18 who have been taking a PPI for more than 4-8 weeks should talk to a doctor, nurse practitioner, or pharmacist about whether stopping a PPI is the right choice for them. …
"Reducing the dose might involve taking the PPI once daily instead of twice daily, lowering the number of mg (e.g., from 30mg to 15mg, or 40mg to 20mg, or 20mg to 10mg depending on the drug), or taking the PPI every second day for some time before stopping."
Patients who have a PPI stopped or reduced are advised to check for and report signs of heartburn, reflux, and/or stomach pain. Caregivers are advised to do the same if they identify loss of appetite, weight loss, and/or agitation.
Credit: Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. Can Fam Physician 2017;63:354-64 (Eng), e253-65 (Fr).
Additional Deprescribing Guidelines
There are a number of other clinical deprescribing guidelines — or guidelines that can help support safe and appropriate deprescribing — that are worth noting.
6. OncPal Deprescribing Guideline
The OncPal deprescribing guideline — with OncPal a combination of "oncology" and "palliative" — is designed to support deprescribing medications for cancer patients with a limited life expectancy. As a Support Care Cancer article notes, the guideline was created by investigating the current literature for the de-escalation of medications by systematically reviewing each medication class according to the European Pharmaceutical Market Research Association anatomical classification list.
The guideline speaks to several classes of medications, including aspirin, lipid-lowering medications, blood pressure-lowering medications, anti-ulcer medications, oral hypoglycaemics, and osteoporosis medications. An adapted version of the guideline can be viewed in this Clinical Medicine column. A HemOnc Today column notes that the guideline has been validated in geriatric oncology for those with an estimated life expectancy of less than six months.
7. American Diabetes Association's Older Adults With Diabetes Deprescribing Guideline
The American Diabetes Association (ADA) has produced what is essentially its own clinical deprescribing guideline in what it describes as "Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with diabetes," published in the ADA's "Standards of Medical Care in Diabetes—2019."
The considerations are broken down by the following patient characteristics/health status:
- Healthy (few coexisting chronic illnesses, intact cognitive, and functional status)
- Complex/intermediate (multiple coexisting chronic illnesses or two-plus instrumental activities of daily living (ADL) impairments or mild-to-moderate cognitive impairment)
- Community-dwelling patients receiving care in a skilled nursing facility for short-term rehabilitation
- Very complex/poor health (long-term care or end-stage chronic illnesses or moderate-to-severe cognitive impairment or two-plus ADL dependencies)
- Patients at end of life
To view the ADA's diabetes deprescribing guidelines, navigate to table 12.2 here.
8. New South Wales Therapeutic Advisory Group Deprescribing Guides
Over in Australia, the New South Wales (NSW) Therapeutic Advisory group, which is comprised of clinical pharmacologists and pharmacists and funded by NSW Health, have published a series of deprescribing guides. They concern the following:
- Psychotropic drugs
- Benzodiazepines and Z drugs
- Antipsychotics for treatment of behavioral and psychological symptoms of dementia
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors
- Tricyclic antidepressants
- Neurological drugs
- Anticholinergic drugs for Parkinsonism
- Genitourinary drugs
- Anticholinergic drugs for urinary incontinence (antimuscarinics)
- Allergy and anaphylaxis drugs
- Sedating antihistamines
- Analgesic drugs
- Regular long-term opioid analgesic use in older adults
- Gastrointestinal drugs
- Proton pump inhibitors
These guides can be accessed here.
In a previous blog, we identified a number of tools that could help safely decrease inappropriate polypharmacy and better support deprescribing efforts. The guidelines provided on Deprescribing.org were on the list, as were the following:
- Medication Appropriateness Index
- Beers Criteria
- Screening tool of older people's prescriptions (STOPP)
- Screening tool to alert to right treatment (START)
- Assess, Review, Minimize, Optimize, and Reassess (ARMOR) protocol
- Good Palliative-Geriatric Practice (GP-GP) algorithm
- Meds 360° platform
Steps to Individualize Deprescribing
While deprescribing guidelines and tools supporting deprescribing should play critical roles in helping clinicians and patients better manage polypharmacy, deprescribing efforts must be individualized to patients. American Family Physician suggests taking these five steps to effectively do so:
- identify potentially inappropriate medications;
- determine if the medication dosage can be reduced or the medication stopped; plan tapering;
- monitor (for discontinuation symptoms or the need to restart) and support the patient; and
- document outcomes.
As the publication notes, "This process seems fairly straightforward; however, each step requires time, careful thought, preparation, and conversation. … To maximize a life worth living for older patients, the focus should be as much on when and how to stop medications as on starting them."