Deprescribing in my opinion can be more important than the act of prescribing but what does this involve? Deprescribing is a term first used in 2003 and is defined by deprescribing.org as ‘planned and supervised process of dose reduction or stopping of medication that might be causing harm or no longer be of benefit’.
Deprescribing has become an integral part of my practice as a Clinical Pharmacist in General Practice, but it all started with a google search in 2019 when asked to prepare a PowerPoint on deprescribing for an interview. I had never heard of the term and simply could not envision how I could talk about the term for 10 minutes. Fast forward a few years down the line and I consider it in almost every consultation I conduct and is intrinsic in all medication reviews especially polypharmacy reviews. Surprisingly since becoming a prescriber – I DEprescribe more so than prescribe. The concept of deprescribing has formed a key part of good prescribing practice.
On an antidepressant that was started 20yrs ago due to a stressful job but now retired? On blood pressure medication but now has low blood pressure? On a proton pump inhibitor whilst on a Non-Steroidal anti-inflammatory medication (NSAID) but no longer on an NSAID? On a long-term benzodiazepine? These are common scenarios we are met with in General Practice when unpacking the back stories to many medications – and becomes the start of the deprescribing road.
Counselling Matters!
Although prescribing and deprescribing are opposing steps – they are strongly interlinked. The ‘reception’ during a deprescribing discussion with a patient or carer during a consultation in a general practice, pharmacy or hospital setting is strongly associated with how it is framed to the patient when prescribed. So when I prescribe folic acid 5mg for folate-deficient megaloblastic anaemia I frame the expectation of ongoing prescribing in stating that this will be prescribed as a once daily dose for 4 months and then stopped, with levels being maintained thereafter with foods that provide a good source of folate. This way a patient has an expectation of duration and the plan going forward.
When starting medication – ensuring a patient centred approach and using wording such as ‘trialling a medication’ or explaining that this ‘will only be required whilst on x medication’ or outlining a duration provides the patient with the understanding and acceptance of the deprescribing consultation. So, we know that just because a medication was needed at a particular time it may no longer be needed i.e. indicated later down the line. The ‘why’ of the medication shapes the ongoing need. Involving the patient in this from the initial stages of prescribing is integral for patient centred, good quality care with shared decision making at the heart of this.
But Why Is Deprescribing Important?
We know medication can be associated with side effects and in some cases long term complications such as increased risk of falls, increased risk of gastric bleeding and increased anticholinergic burden to name a few.
Where Do You Start?
When presented with a deprescribing opportunity or a medication review there are key steps to follow to ensure the consideration is appropriate
1. What is the indication? The ‘why’ of the medication.
Going through the patient’s clinical notes of the patient and/or discussing with them why the medication was initially started helps shape the scene and whether this condition is ongoing.
2. When did they start this medication?
Getting an understanding of when the medication was started by discussion with the patient and/or reviewing their medication notes supports with understanding how long they have been on this medication and if perhaps it was started to counteract another medication. Some medication should only be taken for a set amount of time so being aware of the start date is helpful. The start date is also essential when concerned about medication dependence.
3. Have they been taking this medication as prescribed or perhaps they stopped this but continued to order?
Confirming with the patient the above information is useful as frequency of ordering medication does not give the full picture on compliance.
4. Is this still indicated in relation to current guidance?
Checking current guidance to see if this medication is still indicated or if perhaps guidance has since updated to for example avoid this medication is a key part of the deprescribing process.
5. Do recent bloods or investigations support ongoing use?
In some cases, repeat blood tests and investigations can support in understanding if medication is still required i.e. blood pressure is too low – this would indicate we could consider deprescribing the antihypertensive medication.
6. If not – how do we wean down or stop?
Some medications such as opiates do need to be weaned down while other medications can be stopped immediately.
7. Safety netting the patient as to potential ‘red flags’
Ensuring that the patient is aware of the signs and symptoms to look out for when a medication is weaned down or stopped is essential – for example if a proton pump inhibitor (PPI) is weaned down the patient should be informed to contact the surgery if they experience dysphagia, increased frequency of indigestion, blood in vomit/stool or unexplained weight loss.
Common Medication Culprits
It is important to assess every medication in a medication review however, over the years I have found that there are some common medication culprits that I find that I am commonly deprescribing for various reasons:
1. Aspirin 75mg: ensure it is being prescribed for secondary prevention rather than primary prevention.
2. Proton Pump inhibitors (PPIs): Are they still required? Has the underlying issue been investigated? Is the dose appropriate i.e. on a low dose prevention regime rather than a treatment regime if this is indicated?
3. Folic acid 5mg: Consider how long should they be on this in relation to the indication? For example in folate deficient megaloblastic anaemia – this is for a duration of 4 months.
4. Bisphosphonates: How long have they been on this? Is it time for a bisphosphonate drug holiday?
5. Z-drugs to aid insomnia: e.g. zopiclone, zolpidem. The BNF suggest maximum us of up to 6 weeks. How do we support the patient to wean down and stop? Local services that may support in offering e.g. CBTi
The above outline the top 5 I come across in my daily practice, but the possibilities are extensive, and the list above is not exhaustive in any way. The truth of the matter is that deprescribing is at the heart of every medication review regardless of the age of the patient or the number of medications they are on. We know that the circumstances of a patient, functioning of organs e.g. kidney function, emerging medical conditions and evolving guidance will always shape the need or lack of for all medication so let’s make every consultation and interaction count. Increasing patient education and making them the centre of their medical care supports this further.
Useful Resources For Deprescribing:
- PrescQIPP – contains algorithms to follow on deprescribing of certain medication
- Deprescribing.org – a Canadian organisation which has useful advice and patient leaflets regarding deprescribing of certain medication which does not contain medical jargon providing easy to read and digest information
- STOPP START Toolkit – when medication should be considered to be continued or stopped in older patients.
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