medication wastage in addition to improving overall
patient care. 6–10 There is emerging evidence that
deprescribing can have benefits such as improved
cognition, reduction in falls and improved quality
of life. 11
Definition
Deprescribing can be defined as “the process
of withdrawal of an inappropriate medication,
supervised by a health care professional with the
goal of managing polypharmacy and improving
outcomes.” 12
In order to initiate deprescribing, it is important
to understand a patient’s comorbidities and their
medications, through undertaking a thorough
review of their medicines and assessment of
compliance and adherence. 4 Vitamins and over the
counter (OTC) medicines should not be overlooked;
some OTC medicines can interact with the patient’s
current therapy and be harmful to their health, for
example, St John’s Wort, which can interact with
a number of medicines. 13
Managing deprescribing
Mangin et al describe the need to change
our viewpoint when treating patients with
multimorbidities by taking a more generalist
approach in the management of their medicines
and moving away from treating diseases in their
own individual silos. 14 There is evidence to suggest
that deprescribing can lead to improved outcomes
for patients. 15,16 Initiation of deprescribing is
associated with low relapse rates, with as low as
1.2% of discontinued medicines being restarted; this
was also associated with a significant reduction in
mortality and hospital referrals. 17,18 Deprescribing
has also demonstrated improvement in cognition
following withdrawal of various medicines, mainly
benzodiazepines. 16,17,19
Some disease states, such as cardiovascular
disease, diabetes and dementia, necessitate
polypharmacy that is in line with guideline
recommendations. Prescribers may not feel
confident to deprescribe a medication in view
of the patient’s past medical history, and as such,
polypharmacy may continue. 20 This is also where
prescribers might find it difficult to consider which
disease takes priority, how to tackle this type of
polypharmacy, and whether it needs tackling at all.
Psychotropic medicines can increase the risk of
falls and therefore should be reviewed on a regular
basis to avoid long-term use, particularly in frail and
elderly patients. 21,22 Deprescribing of unnecessary
psychotropic medicines can result in a 66%
reduction in the risk of falls. While deprescribing
of psychotropic medications is advantageous,
symptoms of withdrawal might hinder the process
and often patients are reluctant to reduce and
discontinue their psychotropic medication. 23
Dementia is often associated with behavioural
and psychological symptoms and as a result
psychotropic medications are often prescribed
in this instance. A multidisciplinary approach
to deprescribing in such a scenario is warranted
to overcome challenges and address this type of
polypharmacy. 22
In patients with limited life expectancy or in
those who are considered end of life, deprescribing
of non-critical medications should be considered.
Statins, for example, demonstrate benefit in
reducing cardiovascular morbidity and mortality
over a number of years; therefore their use in such
cases is unlikely to confer any benefit and could be
discontinued. 24,25
Fundamental to
the process of
deprescribing is
a paradigm shift
in the way in
which healthcare
providers view the
prescribing and
administration of
medications
Anticholinergic drugs can have a detrimental
effect on an individual’s cognition, particularly
in the elderly, and can cause side effects, such
as increased heart rate and blurred vision, that
can contribute to an increased risk of falls. 11,27
Anticholinergic receptors are present in the central
nervous system and throughout the body, and
can therefore cause unintended effects. Elderly
patients with comorbidities are more susceptible
to these unwanted effects. 28 Aging Brain Care
has produced a scale in order to calculate the
Anticholinergic Cognitive Burden (ACB) and consider
the existing burden when initiating new medicines.
Anticholinergic use may be linked to an increased
risk of cognitive impairment, 29 decline on the Mini-
Mental State Exam and increased risk of death. 30 The
vast number of medicines prescribed in primary care
have some degree of anticholinergic activity and
the burden is high in patients who are prescribed
multiple ‘low’ or ‘possible’ anticholinergics (as
defined by Aging Brain Care) and therefore might
not be as apparent to general practitioners (GPs). 31
This demonstrates the need to increase awareness
of the ACB and its potential impact on a patient as
shown in Table 1.
Proton pump inhibitors (PPIs) are often prescribed
inappropriately. PPIs have been associated with
the increased risk of Clostridium difficile 32,33 and
other adverse effects such as increased risk of
fractures, kidney disease and community-acquired
pneumonia. 34 Gradual withdrawal of PPIs with no
adverse effects or rebound symptoms following four
weeks of cessation has been demonstrated, 35 and
numerous studies note the inappropriate prescribing
of PPIs and therefore should remain a drug of
interest when considering deprescribing. 36–38
A paradigm shift is required in the prescribing
process, and the concept of deprescribing should
be considered at the point of prescribing in
a four step deprescribing process; “(1) recognising
an indication for discontinuing a medication; (2)
identifying and prioritising the medication(s) to
be targeted for discontinuation; (3) discontinuing
the medication along with proper planning,
table 1
Commonly prescribed anticholinergics
(as defined by Aging Brain Care) 52
ACB Score 1 (Possible) ACB Score 2 (Definite) ACB Score 3 (Definite)
Atenolol, metoprolol Amantadine
Cetirizine Carbamazepine Chlorphenamine
Colchicine Nefopam
Amitriptyline
Clozapine
Diazepam Oxcarbazepine Imiprimine
Digoxin Nortriptyline
Furosemide Olanzapine
Hydralazine Oxybutinin
Isosorbide Paroxteine
Morphine Quetiapine
Ranitidine Solifenacin
Warfarin Trospium
hospitalpharmacyeurope.com | 2018 | Issue 90 | 21