Deprescribing Unnecessary Medications: A Four-Part Process
With too many patients taking too many unnecessary medications, deprescribing has become a required skill for primary care physicians. Here's how to go about it.
Fam Pract Manag. 2018 May-June;25(3):28-32.
Author disclosure: no relevant financial affiliations disclosed.
Related articles from American Family Physician: "Deprescribing Antipsychotics for Behavioral and Psychological Symptoms of Dementia and Insomnia" and "Deprescribing Is an Essential Part of Good Prescribing."
Ms. Horatio is a 76-year-old patient who has been coming to your practice for more than 10 years. She has Type 2 diabetes with stage-3 chronic renal disease and painful diabetic neuropathy of bilateral lower extremities, chronic obstructive pulmonary disease, stable coronary artery disease, and hypertension. She has seen a cardiologist, pulmonologist, and neurologist for additional care. At today's visit with you, her family physician, she has brought a brown paper bag filled with all her medications per your request. Her medications include amitriptyline, atenolol, atorvastatin, low-dose aspirin, diphenhydramine hydrochloride, clopidogrel, conjugated estrogen tablets, ferrous sulfate, glyburide, isosorbide dinitrate, lisinopril, nifedipine extended release, omeprazole, paroxetine, pregabalin, tolterodine, tiotropium inhaler, and zolpidem. Where do you begin?
WHAT IS POLYPHARMACY?
Polypharmacy is typically defined as the prescription of five or more medications. However, it also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated. In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.
Polypharmacy is highly prevalent, especially among older adults. A 2016 study found that 36 percent of community dwelling adults age 62 to 85 were taking five or more medications.1 This is up from 31 percent in 2005. At this rate of increase, almost half of the older population could be affected by polypharmacy by 2030.
Patients at risk for polypharmacy are older than age 62, have comorbidities, have multiple prescribers or pharmacies, self-treat with over-the-counter medications, and have a history of hospitalizations.1,2,3 They also likely go to practices with poor medication tracking processes, including medication lists that are not updated or are inaccurate. Poor medication tracking processes are more prevalent than physicians might think. For example, an internal study at my previous organization found that only 19 percent of office visits to general internists included a medication review.
Polypharmacy has multiple adverse consequences. These include adverse drug events and other safety events such as falls, medication nonadherence, increased mortality, increased cost, and functional impairment. Polypharmacy often begins when a medication causes an adverse drug event, leading to additional treatment, which causes an additional reaction,
Referencesshow all references
1. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs. 2011. JAMA Intern Med. 2016;176(4):473–482....
2. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–834.
3. Vande Griend JP. Common polypharmacy pitfalls. Pharmacy Times. January 1, 2009.
4. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096–1099.
5. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(3):583–623.
6. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33:323–328.
7. McGrath K, Hajjar ER, Kumar C, Hwang C, Salzman B. Deprescribing: a simple method of reducing polypharmacy. J Fam Pract. 2017;66(7):436–445.
8. Pharmacists (Position Paper). Leawood, KS: AAFP; 2018. https://www.aafp.org/about/policies/all/pharmacists.html. Accessed March 28, 2018.
9. Dolovich L. Ontario pharmacists practicing in family health teams and the patient-centered medical home. Ann Pharmacother. 2012;46(4):S33–S39.
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