Deprescribing: a new goal focused on the patient

ABSTRACT

It is estimated that one-fifth of adult patients are treated with polypharmacy (five or more drugs) and the prevalence of this phenomenon in the elderly is even higher, ranging from 30% to 70%, even reaching 90% in residents of residential aged care facilities. Polypharmacy in the elderly increases the risk of adverse reactions, inappropriate prescriptions, drug interactions, number of hospitalizations, costs, and even death. In a recent systematic review, the authors proposed defining deprescribing as ‘the process of withdrawal of inappropriate medication supervised by a health care professional with the goal of managing polypharmacy and improving outcomes’.

KEYWORDS:

• Deprescriptions
• polypharmacy
• pharmacovigilance
• pharmacoepidemiology

It is estimated that one-fifth of adult patients are treated with polypharmacy (five or more drugs) and the prevalence of this phenomenon in the elderly is higher, ranging from 30% to 70%, even reaching 90% in residents of residential aged care facilities [1–4]. Polypharmacy in the elderly increases the risk of adverse reactions, inappropriate prescriptions, drug interactions, number of hospitalizations, costs, and even death [5].

Since 2003 the term ‘deprescribing’ was introduced into the scientific literature in English, seeking to improve outcomes associated with polypharmacy and potentially inappropriate medications in the elderly [2,6], but only in recent years has the term gained strength and diffusion, despite the lack of a formally accepted definition [2]. In a recent systematic review, the authors proposed defining deprescribing as ‘the process of withdrawal of inappropriate medication supervised by a health care professional with the goal of managing polypharmacy and improving outcomes’ [2], while Scott et al. define it as ‘the systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values and preferences’ [3]. Thus deprescribing emerges not only as the simple interruption of a drug, but as a series of steps applied in a rational and consensual manner to improve patient outcome.

The entry terms deprescriptions and deprescribing were only added this year in the Medical Subject Headings. A literature search in PubMed in September 2016 with these terms yields only 118 results, most of them published in the period 2015–2016. There is little mention of these terms in the scientific literature in Spanish, although the term ‘deprescripciones’ was also incorporated into the Health Sciences Descriptors (DeCS) in 2016.

Several deprescribing models have been published, focused especially on elderly patients, although specific areas, such as psychiatry, are already addressing the theme. Each protocol has specific details and items, but in general they can be divided into a full initial evaluation of the case, identifying potentially inappropriate medication, prioritizing drug discontinuation, performing the deprescription and monitoring the result [1,3,6,7], without forgetting the potential risks of this practice [7].

For example, in a multicenter trial of patients on palliative care, it was possible to discontinue statin therapy safely, with a better perception of quality of life and lower costs compared to those who continued treatment [8]. Another recently published trial found that deprescription protocols can be applied in frail elderly patients without adversely affecting their survival [1]. Patient-specific interventions are gaining evidence in mortality reduction effect [9] but more studies are needed to detect the influence of deprescription on multiple outcomes.

The deprescribing process is not free of risk and some potential harms and challenges for its execution have been described, including withdrawal syndromes, rebound effects, pharmacokinetic/pharmacodynamics changes that alter the unstopped drugs metabolism, and recurrence of symptoms that were being treated with the ceased medication [7,10]. Other barriers to deprescription include concerns from the patients or the family, worries and doubts from the physician, and some issues related to each health system (e.g. multiple professionals treat one patient, guidelines focused on interventions) [7].

The different algorithms and especially the concept of deprescription are likely to begin gaining traction and playing a bigger role in the medical community and will be routinely used in different medical centers in the world. However, publications on the subject are still scarce and it would be of interest to find the spaces for its implementation, with interventions and goals focused on the patient, providing education and the monitoring necessary after the discontinuation of drugs.

Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.