Where to start?

You are doing a medication review for an 83-year-old person taking 15 medications. You suspect they may be taking too many medications—and even some that are unsafe. You might have 30 minutes (or less) for this review. Sometimes it can be hard to know where to start.Asyou know, you can’t expect to be able to address every single problem and revamp a person’s drug therapy in one visit.1 It is a process. It might take multiple visits. In assessing the patient and developing your care plan, you might identify some deprescribing opportunities. These might be medications which are unnecessary, potentially unsafe, or which don’t fit with an individual’s care goals or treatment preferences.2 So how do you decide which to stop or reduce first? While the right answer is going to be different for each situation, here are some things to consider. Talk with patients about each of these different aspects to find the best plan for them.Consider risk of harmIf you suspect a patient may be experiencing actual harm from a medication, or is at high risk of experiencing harm, it might make sense to stop or reduce this one first.2 Consider an 80-year-old patient taking ramipril and amlodipine who has been increasingly dizzy and had three falls over the last few months—and has recent blood pressure readings around 105/75 mmHg. A trial of stopping, tapering or reducing the dose of one of these antihypertensives may be a reasonable starting point in the care plan. Harm may be easier to detect for medications started more recently, but even if a patient has been taking a specific medication for several years, think about whether any recent changes (e.g., change in health status, new diagnosis, new concomitant medications) may have shifted the balance of benefits and harms of a long-term medication.Look for unnecessary or unhelpful medicationsConsider medications that are likely providing no or little benefit, or that are unnecessary in the first place.2 Deprescribing these medications may not necessarily make a person feel better, but can be a quick way of reducing pill burden and cost for patients concerned about these factors. For example, stopping vitamins or supplements of questionable benefit,3 or those where there is no clear indication for use can be a place to start. Similarly, docusate sodium is not effective for managing constipation and is an easy target for deprescribing.4Reassessing whether symptom relief medications continue to be helpful or necessary can also reveal places to start. We do not want to stop medications that are safely helping to treat symptoms, but we could think about “legacy prescriptions”1 which people may have been taking for many years without re-evaluation. For example, three- or four-times-daily acetaminophen may no longer be necessary or helpful for a 90-year-old who is not experiencing pain or discomfort.5,6 A gradual reduction in the dose to the point of stopping (along with close monitoring) would reduce pill burden.Find out the patient’s prioritiesAsking the patient which medication(s) they think they could do without, or would like to stop first, can be another way to prioritize deprescribing targets.2 Patients may have ideas about specific medications, such as a patient who is bothered by taking glucosamine tablets that are large and difficult to swallow. It could also be more complicated, such as a patient who wonders about whether they should keep taking their statin for primary prevention; this may require a longer discussion that examines evidence on benefits/harms, as well as patient preferences and healthcare goals.Patients may themselves be motivated to stop or reduce specific medications, which can help with prioritization. For example, a patient may be bothered by a certain symptom or problem which a medication may be contributing to (e.g., ankle edema from gabapentin). A patient may question whether they still need trazodone for insomnia, be concerned about the safety of long-term use, and be curious about trying to reduce the dose. This may make trazodone a clear priority to try stopping or reducing with close monitoring and follow-up.Think about practical considerationsAddressing situations where there is likely harm (or potential for harm) might be a clear starting point. However, prioritizing targets for a deprescribing plan likely also depends on what you are reasonably able to do in your practice. Balance the considerations above with the realities of a busy practice. You may be missing information needed to confidently make a recommendation about a specific medication. You may have doubts about how you will manage to follow up with the patient, or may not have time for the nuanced discussion necessary for deprescribing of some medications. That is OK. Some things may be kept on your radar but not addressed until you have the time and information you need.SummaryThere are many different ways to get started with deprescribing. Consider the ideas presented in this column to help you take the first step.Wade Thompson is a pharmacist and researcher working to ensure older persons are taking medications that are necessary, effective, safe, and consistent with their healthcare goals and treatment preferences. He is an assistant professor in the Department of Anesthesiology, Pharmacology and Therapeutics in the Faculty of Medicine at the University of British Columbia. He is an investigator with deprescribing.org and a member of the Therapeutics Initiative, and works clinically as a pharmacist in long-term care.References:Farrell B, Mangin D. Deprescribing is an essential part of good prescribing. Am Fam Physician 2019;99(1):7-9. http://www.ncbi.nlm.nih.gov/pubmed/30600973 (accessed February 6, 2024).Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324.O’Connor EA, Evans CV, Ivlev I, et al. Vitamin and mineral supplements for the primary prevention of cardiovascular disease and cancer. JAMA 2022;327(23):2334. doi:10.1001/jama.2021.15650.Fakheri RJ, Volpicelli FM. Things we do for no reason: prescribing docusate for constipation in hospitalized adults. J Hosp Med 2019;14(2):110-3. doi:10.12788/jhm.3124.Patterson TG, Beckenkamp P, Ferreira M, et al. Deprescribing paracetamol in pain conditions: a scoping review. Res Social Admin Pharm 2022;18(8):3272-83. doi:10.1016/j.sapharm.2021.11.008.Siebert D, Meyer M, Jensen E. Acetaminophen for pain relief in osteoarthritis. Am Fam Physician 2020;102(2):113-4.

Where to start?

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WADE THOMPSON

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