Deprescribing

What is the definition of deprescribing?

The process of stopping or reducing medicines to eliminate problematic polypharmacy, while monitoring for adverse effects or worsening of disease.

What are four scenarios of problematic polypharmacy?

1. Medicines no longer clinically indicated.

2. Harm outweighs benefit.

3. Combination of medicines causes harm.

4. Practicalities of using medicines become unmanageable.

Name three drivers of polypharmacy.

• Multiple long-term conditions.

• Increasing age.

• Therapeutic advancements and new drugs.

• Increased accessibility to medicines.

• NHS guidance and targets (e.g., QOF, NICE standards).

• Multiple prescribers.

• Psychosocial issues and patient/carer demand.

What is a prescribing cascade?

When an adverse drug event is misinterpreted as a new condition, leading to additional medication being prescribed.

Name three challenges to deprescribing.

• Fear of litigation.

• Poor evidence for stopping therapy.

• Non-adherence and therapeutic failures.

• Poor communication and information transfer.

• Lack of medication reviews.

• Focus on treating conditions rather than the person.

• Limited access to non-pharmacological options.

What does the NO TEARS approach stand for?

• Need and indication.

• Open questions.

• Tests and monitoring.

• Evidence and guidelines.

• Adverse events.

• Risk reduction or prevention.

• Simplification and switches.

What are common adverse effects of anticholinergic medications?

Dry eyes, urinary retention, dizziness, cognitive impairment, and falls.

What is the recommended tapering rate for opioids?

Reduce by 10% weekly or bi-weekly, with close monitoring.

What does STOMP stand for?

Stopping Over-Medication of People with learning disabilities, autism, or both.

What are the key points of STOMP?

• Psychotropic medications are often overused.

• Non-pharmacological interventions should be explored first.

• Tapering should be gradual and involve a multidisciplinary team.

What is the recommended approach to tapering antidepressants?

Reduce daily dose by 25-50% every 2-4 weeks, with regular check-ins to monitor for withdrawal symptoms.

What are the principles of shared decision-making in deprescribing?

• Involve the patient and carer.

• Use open questions.

• Balance risks and benefits.

• Prioritise 1-2 deprescribing issues at a time.

• Document decisions and monitor outcomes.