imported>Fire: Created page with "{{Infobox medical condition (new) | name = Deprescription | synonyms = Deadoption | image = VariousPills.jpg | caption = Reduce medication burden and harm | pronounce = | field = | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medica..."

2023-01-06T03:37:44Z

Created page with "{{Infobox medical condition (new) | name = Deprescription | synonyms = Deadoption | image = VariousPills.jpg | caption = Reduce medication burden and harm | pronounce = | field = | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medica..."

New page

{{Infobox medical condition (new)
| name = Deprescription
| synonyms = Deadoption
| image = VariousPills.jpg
| caption = Reduce medication burden and harm
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| types =
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'''Deprescribing''' is the planned and supervised process of intentionally stopping a [[medication]] or reducing its dose to improve the person's health or reduce the risk of adverse [[side effect]]s. Deprescribing is usually done because the drug may be causing harm, may no longer be helping the patient, or may be inappropriate for the individual patient's current situation.<ref name = "Reeve_2015">{{cite journal | vauthors = Reeve E, Gnjidic D, Long J, Hilmer S | title = A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice | journal = British Journal of Clinical Pharmacology | volume = 80 | issue = 6 | pages = 1254–68 | date = December 2015 | pmid = 27006985 | pmc = 4693477 | doi = 10.1111/bcp.12732 }}</ref><ref>{{cite journal | vauthors = Thompson W, Farrell B | title = Deprescribing: what is it and what does the evidence tell us? | journal = The Canadian Journal of Hospital Pharmacy | volume = 66 | issue = 3 | pages = 201–2 | date = May 2013 | pmid = 23814291 | pmc = 3694945 | doi = 10.4212/cjhp.v66i3.1261 }}</ref> Deprescribing can help correct [[polypharmacy]] and [[prescription cascade]].

Deprescribing is often done with people who have [[Multimorbidity|multiple chronic conditions]], for older people, and for people who have a limited life expectancy.<ref name = "Gnjidic_2012">{{cite journal | vauthors = Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN | title = Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes | journal = Clinics in Geriatric Medicine | volume = 28 | issue = 2 | pages = 237–53 | date = May 2012 | pmid = 22500541 | doi = 10.1016/j.cger.2012.01.006 }}</ref> In all of these situations, certain medications may contribute to an increased risk of adverse events, and people may benefit from a reduction in the amount of medication taken. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life. "Simply because a patient has tolerated a therapy for a long duration does not mean that it remains an appropriate treatment. Thoughtful review of a patient's medication regimen in the context of any changes in medical status and potential future benefits should occur regularly, and those agents that may no longer be necessary should be considered for a trial of medication discontinuation."<ref>{{cite journal | vauthors = Linsky A, Simon SR | title = Reversing gears: discontinuing medication therapy to prevent adverse events | journal = JAMA Internal Medicine | volume = 173 | issue = 7 | pages = 524–5 | date = April 2013 | pmid = 23459795 | doi = 10.1001/jamainternmed.2013.4068 }}</ref>

The process of deprescribing is usually planned and supervised by health care professionals.<ref>{{cite journal |url=https://www.nps.org.au/australian-prescriber/articles/deprescribing-in-older-people|doi=10.18773/austprescr.2020.033 |title=Deprescribing in older people |year=2020 |last1=Liacos |first1=Michelle |last2=Page |first2=Amy Theresa |last3=Etherton-Beer |first3=Christopher |journal=Australian Prescriber |volume=43 |issue=4 |pages=114–120 |pmid=32921886 |pmc=7450772 }}</ref> To some, the definition of deprescribing includes only completely stopping a medication while to others, deprescribing also includes dose reduction as this can improve quality of life (minimizing side effects) while maintaining benefit.<ref name = "Page_2018">{{cite journal | vauthors = Page A, Clifford R, Potter K, Etherton-Beer C |title=A concept analysis of deprescribing medications in older people |journal=Journal of Pharmacy Practice and Research |date=April 2018 |volume=48 |issue=2 |pages=132–148 |doi=10.1002/jppr.1361 |doi-access=free }}</ref>

==Demographics==
Older people are the heaviest users of medications, and frequently take five or more medications (polypharmacy). [[Polypharmacy]] is associated with increased risks of adverse events, drug interactions, [[Falls in older adults|falls]], hospitalization, cognitive deficits,{{Better source needed|date=January 2017}} and mortality. These effects are particularly seen with high risk prescribing.<ref>{{cite journal | url=https://doi.org/10.1016/j.maturitas.2021.06.004 | doi=10.1016/j.maturitas.2021.06.004 | title=Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review | year=2021 | last1=Wang | first1=Kate | last2=Alan | first2=Janine | last3=Page | first3=Amy T. | last4=Dimopoulos | first4=Evelyn | last5=Etherton-Beer | first5=Christopher | journal=Maturitas | volume=151 | pages=1–14 | pmid=34446273 }}</ref> Thus, optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes.

==Evidence base==
{{POV section|date=March 2017}}

Deprescribing is a feasible and safe intervention.<ref name=pmid27077231>{{cite journal | vauthors = Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD | title = The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis | journal = British Journal of Clinical Pharmacology | volume = 82 | issue = 3 | pages = 583–623 | date = September 2016 | pmid = 27077231 | pmc = 5338123 | doi = 10.1111/bcp.12975 }}</ref> Deprescribing results in fewer medications with no significant changes in health outcomes.<ref name = "Potter_2016">{{cite journal | vauthors = Potter K, Flicker L, Page A, Etherton-Beer C | title = Deprescribing in Frail Older People: A Randomised Controlled Trial | journal = PLOS ONE | volume = 11 | issue = 3 | pages = e0149984 | date = March 2016 | pmid = 26942907 | pmc = 4778763 | doi = 10.1371/journal.pone.0149984 | bibcode = 2016PLoSO..1149984P | doi-access = free }}</ref>{{Unreliable medical source|date=August 2016}} A systematic review of deprescribing studies for a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, concluded that adverse effects of deprescribing were rare.<ref>{{cite journal | vauthors = Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG | title = Medication withdrawal trials in people aged 65 years and older: a systematic review | journal = Drugs & Aging | volume = 25 | issue = 12 | pages = 1021–31 | date = 2008 | pmid = 19021301 | doi = 10.2165/0002512-200825120-00004 | s2cid = 25414320 }}</ref><ref name=pmid20937924>{{cite journal | vauthors = Garfinkel D, Mangin D | title = Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy | journal = Archives of Internal Medicine | volume = 170 | issue = 18 | pages = 1648–54 | date = October 2010 | pmid = 20937924 | doi = 10.1001/archinternmed.2010.355 | doi-access = free }}</ref>

By deprescribing medications, prescribers are often able to improve patient function, generate a higher quality of life, and reduce bothersome signs and symptoms. Deprescribing has been shown to reduce the number of falls that people experience, but not to change the risk of having the first fall.<ref name=pmid27077231/> A large systematic review of deprescribing studies found that most health outcomes remained unchanged as an effect of deprescribing.<ref name=pmid27077231/> The absence in a change has been viewed as a positive outcome as the medications can often be safely withdrawn without altering health outcomes. This absence of an effect means that older people may not miss out on potentially beneficial effects of using medications as a result of deprescribing.

Targeted deprescribing can improve adherence to other drugs.<ref name="Gnjidic_2012" /> Deprescribing can reduce the complexity of medication schedules. Complicated schedules are difficult for people to follow correctly.

The Product Information provided by drug companies provides much information on how to start medications and what to expect when using it, though provides very little information on when and how to stop medications.<ref>{{Cite journal| vauthors = Page A, Clifford R, Potter K, Etherton-Beer C |date=2018|title=Informing deprescribing decisions in older people: does the Product Information contain advice on medication use for older people and medication withdrawal?|journal=Journal of Pharmacy Practice and Research |volume=48|issue=2|pages=149–157|doi=10.1002/jppr.1362 |s2cid=79794144}}</ref> Research in to deprescribing is accumulating, with two papers showing a rapid acceleration in the use of the word since 2015.<ref name = "Page_2018" /><ref name = "Reeve_2015" />

==Risks==
It is possible for the patient to develop adverse [[drug withdrawal]] events (ADWE).<ref name=pmid9342997>{{cite journal | vauthors = Graves T, Hanlon JT, Schmader KE, Landsman PB, Samsa GP, Pieper CF, Weinberger M | title = Adverse events after discontinuing medications in elderly outpatients | journal = Archives of Internal Medicine | volume = 157 | issue = 19 | pages = 2205–10 | date = October 1997 | pmid = 9342997 | doi = 10.1001/archinte.1997.00440400055007 }}</ref> These symptoms may be related to the original reason why the medication was prescribed, to withdrawal symptoms or to underlying diseases that have been masked by medications.<ref name="woodward">{{cite journal |last1=Woodward |first1=Michael C |title=Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications |journal=Journal of Pharmacy Practice and Research |date=December 2003 |volume=33 |issue=4 |pages=323–328 |doi=10.1002/jppr2003334323 |s2cid=73918568 }}</ref> For some medications, ADWEs can generally be minimized or avoided by tapering the dose slowly and carefully monitoring for symptoms. Prescribers should be aware of which medications usually require tapering (such as [[corticosteroid]]s and [[benzodiazepine]]s), and which can be safely stopped suddenly (such as [[antibiotics]] and [[nonsteroidal anti-inflammatory drug]]s).

===Monitoring===
Deprescribing requires detailed follow-up and monitoring, not unlike the attention required when starting a new medication. It is recommended that prescribers frequently monitor "relevant signs, symptom, laboratory or diagnostic tests that were the original indications for starting the medication" as well as for potential withdrawal effects.<ref name=pmid20937924/> The recommended schedule for monitoring during deprescribing is at two-weekly intervals.<ref>{{Cite journal |last1=Quek |first1=Hui Wen |last2=Etherton-Beer |first2=Christopher |last3=Page |first3=Amy |last4=McLachlan |first4=Andrew J |last5=Lo |first5=Sarita Y |last6=Naganathan |first6=Vasi |last7=Kearney |first7=Leanne |last8=Hilmer |first8=Sarah N |last9=Comans |first9=Tracy |last10=Mangin |first10=Derelie |last11=Lindley |first11=Richard I |last12=Potter |first12=Kathleen |date=2022-12-19 |title=Deprescribing for Older People Living in Residential Aged Care Facilities: Pharmacist Recommendations, Doctor Acceptance and Implementation |url=https://www.sciencedirect.com/science/article/pii/S0167494322002977 |journal=Archives of Gerontology and Geriatrics |volume=107 |language=en |pages=104910 |doi=10.1016/j.archger.2022.104910 |s2cid=254917543 |issn=0167-4943}}</ref>

==Resources to support deprescribing==

=== Implicit tools ===
Several tools have been published to make prescribers aware of inappropriate medications for patient groups. The most common deprescribing algorithm is validated<ref name = "Page_2016">{{cite journal | vauthors = Page AT, Etherton-Beer CD, Clifford RM, Burrows S, Eames M, Potter K | title = Deprescribing in frail older people--Do doctors and pharmacists agree? | journal = Research in Social & Administrative Pharmacy | volume = 12 | issue = 3 | pages = 438–49 | date = 2016-05-01 | pmid = 26453002 | doi = 10.1016/j.sapharm.2015.08.011 }}</ref> and has been tested in two RCTs.<ref name = "Potter_2016" /> It is available for clinicians to use to identify medications that can be deprescribed.<ref name = "Page_2016" /> It prompts clinicians to consider if it is (1) an inappropriate prescription, (2) adverse effects or interactions that outweigh symptomatic effect or potential future benefits, (3) drugs taken for symptom relief but the symptoms are stable, and (4) drug intended to prevent serious future events but the potential benefit is unlikely to be realised due to limited life expectancy. If the answer to any of the four prompts is yes, then the medication should be considered for deprescribing.

The CEASE algorithm to prompt clinicians to consider if the treated condition remains a current concern for their patient.

The ERASE algorithm prompts clinicians to consider if the treated condition is still requires treatment.<ref>{{cite journal | vauthors = Page A, Etherton-Beer C | title = Undiagnosing to prevent overprescribing | journal = Maturitas | volume = 123 | pages = 67–72 | date = May 2019 | pmid = 31027680 | doi = 10.1016/j.maturitas.2019.02.010 | doi-access = free }}</ref> ERASE mnemonic stands for "'''''e'''''valuate diagnostic parameters", "'''''r'''''esolved conditions", "'''''a'''''geing normally", "'''''s'''''elect targets" and "'''''e'''''liminate"

=== Explicit tools ===
The [[Beers Criteria]] and the STOPP/START criteria present medications that may be inappropriate for use in the elderly.<ref>{{cite journal | vauthors = Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D | title = STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation | journal = International Journal of Clinical Pharmacology and Therapeutics | volume = 46 | issue = 2 | pages = 72–83 | date = February 2008 | pmid = 18218287 | doi = 10.5414/cpp46072 | s2cid = 25532572 }}</ref> For people with dementia, the [[MATCH-D|medication appropriateness tool for comorbid health conditions during dementia]] ([http://www.match-d.com.au MATCH-D]) can help clinicians identify when and what to consider deprescribing.<ref>{{cite journal | vauthors = Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C | title = Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel | journal = Internal Medicine Journal | volume = 46 | issue = 10 | pages = 1189–1197 | date = October 2016 | pmid = 27527376 | pmc = 5129475 | doi = 10.1111/imj.13215 }}</ref>

=== Resources ===
RxFiles, an academic detailing group based in Saskatchewan, Canada, has developed a tool to help [[long-term care]] providers identify potentially inappropriate medications in their residents.<ref>{{cite web|url=http://www.rxfiles.ca/rxfiles/Modules/ltc/ltc.aspx|title=Long-Term Care & Residential Care: Evidence-Based Resources|date=January 2016|website=RxFiles}}</ref> Tasmanian Medicare Local have created resources to help clinicians deprescribe.<ref>{{cite web|url=http://www.cpsedu.com.au/posts/view/46/Deprescribing-Documents-now-Available-for-Download|title=Deprescribing Documents now Available for Download|website=Consultant Pharmacy Services}}</ref>

== Practice changes to encourage deprescribing ==
An expert working group concluded that integrated healthcare provided by multidisciplinary patient-centred teams were the most appropriate approach to promote deprescribing and improve the appropriate medication use.<ref>{{cite journal | vauthors = Page AT, Cross AJ, Elliott RA, Pond D, Dooley M, Beanland C, Etherton-Beer CD |title=Integrate healthcare to provide multidisciplinary consumer-centred medication management: report from a working group formed from the National Stakeholders' Meeting for the Quality Use of Medicines to Optimise Ageing in Older Australians |journal=Journal of Pharmacy Practice and Research |date=October 2018 |volume=48 |issue=5 |pages=459–466 |doi=10.1002/jppr.1434 |s2cid=81405354 }}</ref> The concept of having de-prescribing rounds in tertiary care hospitals has also been evaluated and shown to potentially improve health related outcomes.<ref>{{cite journal | vauthors = Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D | title = Impact of deprescribing rounds on discharge prescriptions: an interventional trial | journal = International Journal of Clinical Pharmacy | volume = 41 | issue = 1 | pages = 159–166 | date = February 2019 | pmid = 30478496 | doi = 10.1007/s11096-018-0753-2 | s2cid = 53730423 }}</ref>

== Barriers and enablers to deprescribing ==

===Barriers===
Although many trials have successfully resulted in a reduction in medication use, there are some barriers to deprescribing:
* the prescriber's beliefs, attitudes, knowledge, skills, and behaviour<ref name="Stowasser">{{cite journal | vauthors = Anderson K, Stowasser D, Freeman C, Scott I | title = Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis | journal = BMJ Open | volume = 4 | issue = 12 | pages = e006544 | date = December 2014 | pmid = 25488097 | pmc = 4265124 | doi = 10.1136/bmjopen-2014-006544 }}</ref>
* the prescriber's work environment, including work setting, health system and cultural factors<ref name="Stowasser" />
* patients' fears about cessation or dislike of medications.<ref name="Reeve">{{cite journal | vauthors = Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD | title = Patient barriers to and enablers of deprescribing: a systematic review | journal = Drugs & Aging | volume = 30 | issue = 10 | pages = 793–807 | date = October 2013 | pmid = 23912674 | doi = 10.1007/s40266-013-0106-8 | s2cid = 13317143 | url = https://unisa.alma.exlibrisgroup.com/view/delivery/61USOUTHAUS_INST/12142886050001831 }}</ref>

=== Enablers ===

*the prescriber's beliefs, attitudes, knowledge, skills, and behaviour<ref name="Stowasser" />
* the prescriber's work environment, including work setting, health system and cultural factors<ref name="Stowasser" />
* the patient's agreement that deprescribing was appropriate,<ref name="Reeve" />
* a structured process for cessation,<ref name="Reeve" />
* the patients' need for influences or reasons to cease medication,<ref name="Reeve" />

The prescriber and patients were shown to have the greatest influence on each other rather than external influences. 9 out of 10 older people said they would be willing to stop one or more medicine if their doctor said it was okay.

== See also ==
* [[Polypharmacy]]
* [[MATCH-D|Medication Appropriateness Tool for Comorbid Health Conditions During Dementia (MATCH-D)]]
* [[Beers criteria|Beers Criteria]]
* [[Medication discontinuation]]
* [[Overmedication]]
* [[Prescription cascade]]
* [[Drug interaction]]

== References ==
{{reflist}}

== Further reading ==
{{refbegin}}
*{{cite journal | vauthors = Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, Gnjidic D, Del Mar CB, Roughead EE, Page A, Jansen J, Martin JH | title = Reducing inappropriate polypharmacy: the process of deprescribing | journal = JAMA Internal Medicine | volume = 175 | issue = 5 | pages = 827–34 | date = May 2015 | pmid = 25798731 | doi = 10.1001/jamainternmed.2015.0324 | url = https://espace.library.uq.edu.au/view/UQ:360882/UQ360882_OA.pdf }}
* {{cite web | vauthors = Page A, Potter K, Clifford R, McLachlan A, Etherton-Beer C | title = Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D): Consensus recommendations from an interdisciplinary panel of experts. | work = International Pharmaceutical Federation (FIP) World Congress 2016 | url = http://www.match-d.com.au }}
* {{cite journal|title=European Journal of Hospital Pharmacology TOC|journal=Eur J Hosp Pharm|date=Jan 2017|volume=24|issue=1|url=http://ejhp.bmj.com/content/24/1.toc}} A special issue on deprescribing
* {{cite journal | vauthors = Hilmer SN, Gnjidic D, Le Couteur DG | title = Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients | journal = Australian Family Physician | volume = 41 | issue = 12 | pages = 924–8 | date = December 2012 | pmid = 23210113 | url = http://www.racgp.org.au/afp/2012/december/medication-list/ }}
* {{cite journal | vauthors = Page AT, Potter K, Clifford R, Etherton-Beer C | title = Deprescribing in older people | journal = Maturitas | volume = 91 | pages = 115–34 | date = September 2016 | pmid = 27451330 | doi = 10.1016/j.maturitas.2016.06.006 }}
* {{cite journal | vauthors = Potter K, Page A, Clifford R, Etherton-Beer C |title=Deprescribing: a guide for medication reviews |journal=Journal of Pharmacy Practice and Research |date=December 2016 |volume=46 |issue=4 |pages=358–367 |doi=10.1002/jppr.1298 |s2cid=78426240 }}
{{refend}}

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{{Unnecessary health care}}
{{二次利用|date=3 January 2023}}
[[Category:Pharmaceuticals policy]]
[[Category:Geriatrics]]
[[Category:Drugs]]
[[Category:Clinical pharmacology]]

Deprescribing - Revision history