Deprescribing Principles

Deprescribing Fundamentals - Un-Pilling Patients

• Definition: A structured, supervised process of withdrawing inappropriate medications where potential harms outweigh benefits.
• Primary Goal: Minimize polypharmacy, reduce adverse drug events (ADEs), pill burden, and improve patient outcomes & quality of life (QoL).
• Why Essential?
  • Addresses risks of polypharmacy (≥ 5 drugs), common in geriatrics.
  • Mitigates ↑ ADEs, drug interactions, non-adherence.
  • Accounts for age-related pharmacokinetic/pharmacodynamic changes.
• Core Approach: Patient-centered, involving shared decision-making with patient/caregivers.
• Focus Areas: Medications lacking clear current indication, high-risk drugs (e.g., Beers criteria), or those with safer, effective alternatives.

⭐ Deprescribing is a systematic process of identifying and discontinuing medications where harms outweigh benefits, particularly crucial in geriatric patients with polypharmacy.

Identifying Candidates - Spotting PIMs

• Geriatrics:
  • Tools: Beers Criteria, STOPP/START.
  • Focus: Polypharmacy (≥5 drugs), high-risk drugs (e.g., anticholinergics, BZDs).
  • Watch for: Drug-drug/drug-disease interactions.
  • Triggers: ADEs, falls, cognitive decline, new symptoms.
• Pediatrics:
  • Concerns: Off-label use, weight-based dosing errors.
  • Review: Meds with unclear benefit, continued past indication, long-term risks.
  • Triggers: Condition resolved, age/weight changes, side effects.
• Universal Steps:
  • Comprehensive medication review (e.g., brown bag).
  • Assess each drug: Indication, efficacy, safety, adherence.
  • Consider patient goals.

⭐ In geriatrics, the Beers Criteria and STOPP/START tools are essential for identifying Potentially Inappropriate Medications (PIMs); in pediatrics, off-label use and weight-based dosing errors are key concerns for deprescribing.

Deprescribing Process - Pill Purge Protocol

• Aim: ↓ Pill burden, ↓ Potentially Inappropriate Medications (PIMs), ↓ Adverse Drug Events (ADEs).
• Process (📌 RASPM):
  • Review: Identify PIMs (e.g., Beers Criteria, STOPP/START).
  • Assess: Risk vs. benefit for each medication.
  • Share: Decisions with patient/caregiver.
  • Plan: Withdrawal strategy.
    • Taper: Essential for drugs with withdrawal syndromes (e.g., benzodiazepines, opioids, β-blockers, SSRIs). Dose ↓ by 25-50% every 1-4 weeks (varies by drug/patient).
    • Stop: Abrupt discontinuation possible for some drugs if low withdrawal risk.
  • Monitor: Closely for Adverse Drug Withdrawal Events (ADWEs), symptom recurrence, or new issues. Regular follow-up.

⭐ Successful deprescribing hinges on a structured approach: medication review, risk-benefit assessment, shared decision-making with patient/caregiver, planned withdrawal, and close monitoring for adverse drug withdrawal events or symptom recurrence.

Barriers & Strategies - Hurdles & Hops

• Hurdles (Barriers):
  • Prescriber-Related:
    • Therapeutic inertia; fear of adverse outcomes, relapse
    • Lack of time, specific training, or clear guidelines
  • Patient-Related:
    • Strong belief in medication necessity; fear of illness worsening
    • Reluctance to question medical advice
  • System-Related:
    • Fragmented healthcare; insufficient consultation time

⭐ Key barriers to deprescribing include prescriber reluctance (e.g., fear of consequences, therapeutic inertia) and patient factors (e.g., belief in medication necessity, fear of illness relapse).

• Hops (Strategies):
  • Prescriber-Focused:
    • Continuous education; utilize deprescribing tools (e.g., Beers, STOPP/START)
    • Conduct regular medication reviews; employ gradual tapering
  • Patient-Focused:
    • Promote shared decision-making (SDM); provide clear education
    • Actively address patient concerns and expectations
  • System-Focused:
    • Implement multidisciplinary team approach (incl. pharmacists)
    • Integrate deprescribing protocols into routine clinical care

High‑Yield Points - ⚡ Biggest Takeaways

• Deprescribing is a planned process of reducing or stopping medications that are no longer beneficial or are causing harm.
• Crucial in geriatrics due to polypharmacy and altered pharmacokinetics/pharmacodynamics.
• Key tools include Beers Criteria and STOPP/START criteria for identifying inappropriate medications.
• Prioritize stopping drugs with high risk and low benefit, considering the patient's goals.
• Patient and caregiver involvement is essential for shared decision-making and successful deprescribing.
• Gradual withdrawal is often preferred to avoid adverse drug withdrawal events or rebound symptoms.
• Regular medication review is a cornerstone of deprescribing, especially after transitions of care.