Deprescribing: a brave new word?

Recently, a colleague and I conducted a literature search concerning the stopping of medicines. Our search terms included ‘cessation’, ‘discontinuation’, ‘withdrawal’ and ‘stopping’, and we found some relevant studies, but not as many as we expected and felt that we must be missing something. We spoke to an Australian colleague who mentioned in passing the term ‘deprescribing’ which led us to rerun our search with greater success. Although not in common parlance in the UK, as far I can discern, deprescribing was first used a decade ago in Australia by Woodward to describe the cessation of medicines.[1] Iyer et al. in their 2008 paper have described it as ‘medication withdrawal in older people’[2] and, more recently, it has been defined as ‘cessation of long-term therapy, supervised by a clinician’.[3] It is important to have a defined term to ensure shared understanding, and as advocated by Iyer et al.,[2] ‘deprescribing’ should be adopted internationally by researchers and practitioners engaged in this area. There are many reasons why it may be desirable to withdraw a medicine from a patient: lack of efficacy, actual or potential adverse drug reactions, non-adherence, resolution of the condition, development of a contraindication, introduction of an interacting drug, to name a few. Most of the deprescribing literature focuses on older people; however, the above reasons could apply to any patient. Nevertheless, there is a great deal of evidence of inappropriate prescribing in older people and they generally bear much of the burden of unnecessary polypharmacy with its associated morbidity. Coupled with the weak evidence-base for pharmacotherapy in older people, this population should be prioritised for deprescribing. Although the evidence-base for deprescribing is limited due to mainly small, non-randomised or non-controlled studies, the weight of evidence shows that for most medicines included in the studies, deprescribing is not harmful in the majority of frail, older people and may be beneficial.[3,4] For example, withdrawal of antipsychotics for challenging behaviour in dementia has been shown to reduce mortality in a randomised, placebo-controlled trial.[5] Garfinkel and Mangin, in a prospective cohort design, assessed the feasibility of the Good Palliative-Geriatric Practice algorithm in 70 older people over a mean follow-up period of 19 months and found that only 2% of 256 discontinued medicines needed to be restarted.[6] A similar previous study by the same authors in nursing home residents found that 10% of 332 medicines required restarting.[7] However, cessation of some medicines, particularly those affecting the central nervous system and the cardiovascular system, has the potential to cause adverse drug withdrawal events or recurrence of disease. Caution needs to be exercised when stopping these medicines, for example opioids, digoxin, diuretics, levodopa, corticosteroids, benzodiazepines and selective serotonin reuptake inhibitors.[2,4,8] Slow withdrawal over a longer duration is often necessary. More empirical evidence is needed from high-quality, randomised, placebo-controlled trials to determine the outcomes of deprescribing, particularly for frail, older people prescribed multiple medicines. But if the existing evidence shows that in the majority of cases discontinuing inappropriate medicines in frail, older people is not harmful and potentially beneficial, why has it been so difficult to implement? There are many barriers to deprescribing including system, clinician and patient factors.[8] An in-depth discussion of all the barriers is not possible here; however, a few have been identified below to highlight some of the different factors. An admission to hospital offers a potential opportunity to review and discontinue unnecessary treatment. Despite this, in the author’s experience in secondary care in the UK, clinicians will often not review long-term medicines that are not directly related to the current admission –“That’s the GP’s job”. However, when a patient is discharged back to the community, the general practitioner (GP) assumes that all the medicines on the discharge prescription have been evaluated, by specialists, as being appropriate to continue. Consequently, medicines may be prescribed ad infintum without considered review. A qualitative study of the views of Dutch GPs in very elderly patients found one barrier to deprescribing was that GPs felt obliged to adhere to clinical guidelines.[9] However, clinical guidelines are usually based on evidence from trials of young people with single conditions and are therefore not often generalisable to older people with several comorbidities. Another barrier was that GPs did not discuss quality of life versus life expectancy with older people;[9] discussions around life expectancy and quality oflife are obviously challenging but without these, it is impossible to elicit patient preferences and to have meaningful dialogue in relation to the risks and benefits of medicines. Anecdotally, prescribers for care home residents have been described by care home staff as ‘brave’ if they were willing to discontinue medicines if a resident was not benefiting or was declining treatment. It is striking that this logical and rational practice is seen as an exception, rather than the rule. It is therefore, important for pharmacists to have an insight into prescribers’ perceptions of stopping medicines to be able to effectively influence their behaviour. Clearly, patients need to be at the centre of decisions to withdraw their medicines. Discontinuing medicines that people have been prescribed for many years can lead to great anxiety and may give the perception that they are not worth treating or that it means their life expectancy must be short. Consequently, pharmacists need to ensure they adopt a patient-centred, sensitive and ethical approach. Transparency is fundamental and lessons should be learned from the withdrawal of the Liverpool Care Pathway last year in the UK; this pathway, designed to provide high-quality palliative care, was withdrawn largely because of a lack of patient and carer involvement in its application in clinical practice. There is a paucity of research on the patient perspective of deprescribing and this significant gap in the literature needs to be addressed. However, a synthesis of qualitative studies of medicine taking showed that people generally prefer to take as few medicines as possible.[10] Withdrawing medicines requires careful consideration, effort, commitment and time. Pharmacists have the skills and knowledge to do this and should be responsible and accountable for creating and implementing deprescribing plans with patients, while ensuring they are supported to safely withdraw their inappropriate medicines. Frameworks for deprescribing have been described in the literature[3,8,11,12] and strategies to effectively implement them need to be developed and tested. Deprescribing is not about denying effective treatment to people who will benefit, it is about ensuring people do not receive unnecessary treatment which is unlikely to be of benefit and may cause harm.