A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms

ABSTRACT

Introduction: As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications.

Areas covered: This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal.

Expert opinion: More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

KEYWORDS:

• Adverse drug withdrawal reactions
• deprescribing
• doctor-patient relationship
• drug-drug interactions
• drug safety
• older adults
• risk management

Article highlights

• Overall, the chance of serious harm from adverse drug withdrawal events (ADWEs) appears to be rare, especially if tapering is conducted. However, there is a need for larger randomized controlled trials to accurately estimate the prevalence and potential severity of ADWEs from deprescribing as well as determining the best strategy for reducing the risk of ADWEs.

• Mitigating the risks associated with return of condition involves close monitoring, tailored to the individual and medication in question with re-initiation of the medication (or initiation of alternative drug or non-drug treatment) where a return in condition is suspected or confirmed.

• Several predictors have been found to increase the risk of return of condition after medication withdrawal including previous indication for use and characteristics of the individual. The predictors appear to be specific to the medication/medication class.

• Little research is available to guide the management of reversal of drug-drug interactions upon deprescribing, however, general principles of management of drug-drug interactions (i.e. monitoring based on known pharmacokinetic and pharmacodynamic properties) can be employed.

• Both prescribers and patients/caregivers believe that a pre-existing good relationship coupled with clear and open communication to achieve shared-decision making are beneficial for positive deprescribing interactions.

This box summarizes key points contained in the article.

Declaration of interest

ER is supported by an NHMRC-ARC Dementia Research Development Fellowship. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.