Taking More than Five Medications? Perhaps it is Time to Think About Deprescribing

Posted on January 17, 2023

Deprescribing came to my attention last week – an unfamiliar term appeared in two different email address boxes, two different days, two different topics on the subject and two different sources. So glad I decided to investigate. . . I was pleased to learn that deprescribing is actually a process I’ve had some success with.

Deprescribing came to my attention last week – an unfamiliar term appeared in two different email address boxes, two different days, two different topics on the subject and two different sources. So glad I decided to investigate. . .

I was pleased to learn that deprescribing is actually a process I’ve had some success with. The opposite of prescribing medication, deprescribing is medication withdrawal. The goal is to improve patient outcomes and quality of life by stopping unnecessary, inappropriate or potentially harmful drugs. Older adults over the age of 65, taking at least five and possibly upwards of 10 different prescription drugs[i] are particularly vulnerable to problems associated with taking too much medication, also referred to as polypharmacy.

Likely prescribed for good reason, however over time some drugs may no longer be helpful, and in fact can even cause harm. For example, some medications can trigger bad reactions when combined with others or may cause side effects such as fuzzy thinking, weakness, falls, disability and even death. Other worries and frustrations related to medications include:

· The hassle of having so many pills to take.

· Frustration with medication costs.

· Wondering whether a given medication is the “right” one for you, or for your condition.

· That sneaky feeling that some of those medications don’t seem to help much.

· The hassle of coordinating a long medication list among multiple doctors.[ii]

Deprescribing isn’t something that you can do for yourself or a family member. You should always work with a health professional before stopping or reducing any prescription medications. I recommend making a point of annually, perhaps during your physical exam, getting into the habit of a focused review with your primary care provider (PCP).

If you haven’t yet done so, create an accurate and up-to-date list of ALL the drugs you are currently taking. This includes:

· Current and recent prescriptions

· Current and recent non-prescription medicines

· Current and recent vitamins and supplements, Herbal remedies

· Vaccination history

· Details of tobacco, alcohol, or recreational drug use

Better yet, bring those medications with you to your annual physical exam for your PCP to review.

Also, keep in mind the medication list that is on your chart or medical record can be inaccurate or out of date, particularly if you are regularly seeing more than one doctor.

Deprescribing comes down to doctors and patients annually asking each other. Review the reason each medication has been prescribed, by asking these questions:

· Is this medication still needed?

· Does the likely benefit of this medication outweigh any risks or harms that it might cause?

· Could we manage without this drug, or could we make do with a lower dose of it?

Six areas to focus on when a topic of the office visit is deprescribing:

1. Ask your doctor if the use of each medication is in line with best practice guidelines and likely to benefit, based on good clinical evidence.

2. Are there safer alternatives available? It is often possible to treat a given health concern with non-drug alternatives, or with medications that are less risky for older adults.

3. Together consider whether the medication:

· providing symptom relief by providing a meaningful benefit

· is likely to be risky, or cause harm

· is a likely benefit being a good fit for your health situation and values.

For instance, if the likely benefit is a 1-in-60 chance of avoiding a heart attack over the next 10 years, this may be more worthwhile to someone in their 60s than to someone in their 90.[iii]

4. Discontinue or reduce dosages of medication when possible. Keep in mind many medications will require a tapering process, in which the dose is lowered over time.

5. For older adults, understand that clinicians should pay special attention to medications known to be risky in seniors, such as those on the Beers List of “Medications that Older Adults Should Avoid or Use with Caution.”

6. Make a plan to follow-up on the deprescribing plan. It’s essential to follow-up after medication changes, to check on related symptoms or health conditions.

As is my practice, regularly remind your doctor(s) that your goal is to be on the minimum number of medications necessary. Over the course of the last three years, I have been able to discontinue medication for high blood pressure after regularly getting low blood pressure readings at home.

I began by daily morning monitoring my blood pressure then sharing those readings with my PCP during an annual visit. With 6 months of data in hand, he was able to verify my regular and consistent lower blood pressures. He suggested I drop down to half a tab – where I remained at that dose for 18 months.

A year ago, the medication was discontinued. I continue to monitor, now twice a week and will share these readings during my upcoming annual physical this spring.

For additional information on this topic, see also: Michael Steinman, MD, Emily Reeve, BPharm(Hons) PhD 4/22/21 https://www.uptodate.com/contents/deprescribing.

[i] Is it time for a medication review? Many people take unnecessary meds. McMaster Optimal Aging Portal: McMaster University, 4/10/17. https://www.mcmasteroptimalaging.org/blog/detail/blog/2017/04/10/is-it-time-for-a-medication-review-many-people-take-unnecessary-meds
[ii] Deprescribing: How to Be on Less Medication for Healthier Aging. Leslie Kernisan, MD MPH. https://betterhealthwhileaging.net/author/leslie-kernisan-md-mph/
[iii] Is it time for a medication review? Many people take unnecessary meds. McMaster Optimal Aging Portal: McMaster University, 4/10/17. https://www.mcmasteroptimalaging.org/blog/detail/blog/2017/04/10/is-it-time-for-a-medication-review-many-people-take-unnecessary-meds