5 Keys to Deprescribing Medications
Tired of taking so many drugs? You may be a candidate for deprescribing
Medicine cabinets often have a story to share. The mix of medications in yours may tell the tale of someone who takes one drug to offset the side effects of another, not realizing that changing the original prescription might eliminate the need for that second one. Or maybe your medicine cabinet suggests two specialists are each prescribing drugs on your behalf, which explains why you’re taking more than one drug from the same class of medication. Each is a potential reason for “deprescribing,” a prescription in itself for what experts call polypharmacy, the simultaneous use of multiple drugs for one or more conditions.
“An increasing number of people—typically those who are older and have multiple chronic conditions—are taking drugs and supplements they don’t need, or they’re taking so many of them that those substances are interacting with one another in harmful ways,” says diabetes educator Caroline Trapp, DNP, ANP-BC, CDE, FAANP, director of diabetes education and care for the Physicians Committee for Responsible Medicine. “Research shows that some patients can improve their health with fewer drugs.”
Could that be you? Keep reading for answers to five key questions about deprescribing.
1. What is deprescribing?
It’s the relatively new process of discontinuing or cutting back on one or more drugs when the existing or potential harms outweigh the existing or potential benefits. The thinking behind it: Medications that made sense when your doctor prescribed them might not be the best choice now.
2. How do I know if I’m a candidate for deprescribing?
Medication use can start to multiply in middle age—even earlier for people with diabetes. “Within the first year of diagnosis for type 2, it’s not uncommon for someone to be taking three to five drugs. And that’s just for diabetes,” says Rohit Moghe, PharmD, MSPH, CDE, an advanced practice pharmacist with a focus in geriatrics and endocrinology at Thomas Jefferson University Hospital in Philadelphia. “It doesn’t include cholesterol and blood pressure meds, which are often prescribed as well.”
But just because you’d like to cut back on your medications doesn’t mean you should. It’s a decision you and your health care provider need to make together. Older people who take multiple medicines tend to be good candidates because they’re at greater risk for negative drug effects such as drowsiness and falls. In fact, research shows that, for older adults, 1 in 4 hospitalizations are caused by medication-related problems. Those who are frail are even stronger candidates for deprescribing, according to research published in 2014 in the Canadian Medical Association Journal. Frail patients tend to take more drugs and have more negative outcomes related to medications than other older adults, the researchers reported.
Your doctor may suggest deprescribing for other reasons, too: Maybe after years of use, a certain medication is no longer doing its job. Or maybe you’re on two drugs from the same class and your doctor believes taking only one of them will provide the same benefits.
Your doctor will be the ultimate judge of whether it makes sense to deprescribe a medication, but your pharmacist can also play a role. Ask if he or she will review your meds, including any vitamins or dietary supplements you’re taking. “A lot of pharmacies do medication reviews as a free public service,” notes Moghe. If yours doesn’t, you may be eligible to get your review at no cost through a medication therapy management program. You must be enrolled in a Medicare drug plan and take medications for different conditions. For more details, go to medicare.gov.
3. What are the benefits of deprescribing?
Going off of unnecessary medications can get rid of unpleasant or dangerous side effects, make it more likely you’ll take your other meds as directed, and lower health care costs, among other things, suggests research published in 2014 in the journal Expert Opinion on Drug Safety. Deprescribing also eases the daily burden of managing your meds. “If you’re taking five pills a day, that’s more than 1,800 a year,” says Moghe. “A lot of people get fatigued.” As a result, they miss doses or quit refilling prescriptions.
4. Are there risks?
According to a review of recommendations for deprescribing published in the March 2017 issue of the European Journal of Internal Medicine, the risks of deprescribing include reactions to withdrawal that can range from unpleasant to harmful and a return of the medical condition itself, but in a heightened state—what’s known as the “rebound effect.” But these can be minimized with proper planning, close monitoring by your health care provider, and getting back on the medication if necessary (see “Safe Deprescribing,” below).
The biggest mistake you can make is leaving your doctor out of the process. “Deprescribing without medical supervision is never recommended,” says Moghe, who notes that some blood pressure medications and antidepressants must be tapered. “If they’re not tapered properly, you’re at risk of a rebound effect that’s more dangerous than the condition you’re managing.”
5. How can I avoid getting on so many drugs to begin with?
When your doctor prescribes a medication, discuss the expectations of the drug and when, or if, you’ll be able to consider going off of it, says Trapp. Another thing to keep in mind: If you see a number of health care providers—and people with diabetes often do—pick one to oversee all your meds. That way you’ll avoid the kind of miscommunication that leads to prescriptions for two drugs that do the same thing. Another smart idea: If possible, fill all of your prescriptions at the same pharmacy.
Ready to cut back on your meds? Never go cold turkey. Here’s how you and your health care provider can approach the process of deprescribing, according to guidelines published in 2015 in JAMA Internal Medicine.
You and your doctor will:
- Review the medications you’re currently taking and the reasons for each. Be sure to include any dietary supplements and over-the-counter drugs.
- Evaluate your specific risk of experiencing the harmful effects of a drug in order to determine whether it makes sense for you to reduce the dosage or discontinue the drug altogether.
- Compare each drug’s current or future potential benefit with its current or future potential harm.
- Categorize the drugs you’ll discontinue, giving priority to those that are least likely to cause withdrawal symptoms or a rebound effect, as well as those for which the potential harm of staying on the drug outweighs the benefit. If you’re going off of multiple meds, you’ll likely do it one at a time so your physician can better manage any symptoms.
- Create a plan of action, including how your doctor will monitor your progress. Share that plan with your caregivers and everyone else on your health care team. Be sure you know which withdrawal symptoms to look for and whom to contact if you experience any of them.