We all know about prescribing. It’s what our docs do when they pull out the prescription pad so we can start or keep taking a specific drug for a specific medical reason.
But have you heard about deprescribing?
Basically, deprescribing happens when a health care professional decides to taper or stop recommending one or more prescription drugs for any given patient. The practice is aimed at minimizing what’s known as polypharmacy (that’s when adult patients are taking multiple medications at the same time) while at the same time improving patient outcomes.
What’s the problem with polypharmacy? Plenty, as it turns out.
Consider this simple example from Lisa, a patient living with a number of medical conditions whose daily medication burden seems truly overwhelming – on top of her implanted cardiac defibrillator and the CPAP machine she’s hooked up to all night, every night. She explains the reality from a patient’s perspective:
“I’m sitting here looking at my pillbox: 15 pills in the morning, three in the afternoon, and nine more in the evening, then one more injection every month. Before every doctor’s appointment, I stand over my pillbox and ask myself what could be culled, especially at my annual physical. I would love it if a physician would tell me what we should cut.
“Most of my conditions have been under control for more than a year, some 3-5 years. The control came mostly through exercise and diet. But my doctors are saying: ‘We have this under control. Let’s not change anything.’
“So how can I get off any of these medications?”
Lisa’s not alone in believing that sometimes, “less is more” when it comes to pharmaceuticals.
But keep in mind that it’s not just the number of prescription drugs you’re taking that should concern you, but this question:
“Are you taking more medications than are clinically necessary?”
Taking any drug that is not appropriate is, by definition, exposing you to more harms than benefits; therefore, not taking an inappropriate medication will lead to a better overall risk–benefit profile and, very likely, better patient outcomes.
Here’s a small, non-scientific illustration: I’ve written many times about why patients don’t take their meds (here, here, and here, for example) – each time followed by a number of readers reporting that they had specifically stopped taking the anti-hypertensive drugs they’d been prescribed in hospital after surviving a heart attack. In every case, these women did not then or ever have high blood pressure, and the drugs caused them unpleasant side effects that made them feel dizzy, weak or faint. Every time I heard from readers like this, I began to wonder if drugs to lower blood pressure are being routinely prescribed as part of a standard one-size-fits-all parcel of cardiac drugs (along with beta blockers and statins) to all freshly-diagnosed heart patients – even for those with low blood pressure who clearly don’t need them.
Cardiologist Dr. John Mandrola calls deprescribing an important new “action verb in doctoring” in his editorial in the Journal of the Kentucky Medical Association:
“The act of prescribing lies at the core of what doctors do to help patients. Sadly, these days, most of what we advocate for are chemical modulators of body systems — pills. It doesn’t have to be this way; we could authorize smarter eating habits, more exercise, sleep hygiene and stress management strategies.
“But these are hard, and pills are easy.
“As modern medical technology advances, and people live longer but with more chronic diseases, the act of deprescribing has never been more relevant.”
Researchers suggest that inappropriate polypharmacy can impose a substantial burden of adverse drug reactions, ill health, falls, cognitive decline and more – enough so that there’s often genuine uncertainty about which is greater: the benefit or the risk of taking these meds.
In fact, the single most important predictor of inappropriate prescribing and risk of adverse drug events is the number of prescribed drugs being taken by a patient.
But if a person has been taking a medication that was at one time prescribed for a good reason, isn’t deprescribing that drug dangerous to that person?
Surprisingly, research suggests that reducing the number of drugs more often actually has a positive outcome, particularly in older people. A feasibility study to reduce polypharmacy in patients over 70 years of age, for example, found that over half of their medicines could be safely discontinued. Only 2% of the drugs needed to be restarted because the original indication re-emerged. But among those who were successfully discontinued, there was actually improvement in both cognition and the patients’ overall health.(1)
That’s also what University of Victoria health policy analyst Alan Cassels found when he looked for published research on potential harm to patients if they did NOT take their prescription drugs as directed. He was surprised to learn there are actually very few scientific studies available. In his Common Ground column last winter, he cited a systematic review by the Cochrane Collaboration which found that, even though only about half of all patients take their medication as prescribed, there was little evidence to show that this actually made much of a difference after all. In fact, only five of 180 studies could show any improvements in health outcomes for patients when they took all their meds as directed.(3) The shocking conclusion of the review authors was this:
“Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.”
An Australian report on deprescribing reminds us that good basic medical practice also requires a regular medication review of every patient’s prescription drug list by the patient’s physician. It’s an excellent opportunity to consider deprescribing, especially for people living with more than one chronic illness diagnosis, or for whom treatment goals may have changed.(2)
So if you’ve been taking the same batch of prescription meds for an extended period of time without having had a full medication review lately, ask your health care provider to discuss your meds with you.
Dr. David Le Couteur, this study’s lead author, warned his colleagues specifically about paying attention to adverse side effects of prescription drugs:
“Given that clinical drug trial participants do not always reflect real-life patients, it is likely that a greater number of patients in everyday practice will be unable to tolerate their medicines.
“Health professionals often have difficulty recognizing adverse drug reactions, partly because they are reluctant and unwilling to recognize them and partly because the reactions can be mistaken for symptoms of disease.”
A medication review should also assess if the drug is doing the job it was originally prescribed to do – particularly for drugs that don’t treat existing illness, but are prescribed to possibly prevent possible future illness – if possible. But as Dr. Le Couteur reminds us:
“For many drugs, it is not possible for any individual clinician to assess effectiveness. If a drug has no effect on symptoms or a surrogate outcome (for example blood pressure or cholesterol measurements), then it is pointless to continue therapy because it accrues cost and the risk of harm without any benefit.”
Here’s how cardiologist Dr. Anthony Pearson describes the medication review for his heart patients, asking himself the following questions:
Does the patient need this medication?
Is he/she having side effects from the medications?
Is this the right dosage?
Are there any interactions between the medications that are important?
Is there a cheaper or safer alternative?
For many patients, he will reduce or stop what he considers to be unnecessary medications. Often, he explains, this results in the patient feeling better, and “sometimes this is live-saving.”
Open communication with one’s health care provider is rarely more important than when discussing the pros and cons of putting drugs into your body.
For example, Jane (one of my blog readers) wrote me last month that she had recently stopped taking one of the meds that her cardiologist had prescribed for her, but not for the reasons you might expect. She explained:
“The reasons for my lack of compliance? The cardiologist is treating drugs as though any drug will do – there is no fine tuning (“You can stop taking it if you don’t want to take it”) – and, as I recall, it was – as usual – ME who asked:
“How about THIS drug”?
“Calcium channel blocker? Beta blocker? Others? I’ve lost track of how many hours I’ve spent reading case studies and comparisons of these drugs.
“But am I qualified to make any determination? Absolutely not. But is my cardiologist? If he is, he hasn’t presented a rational argument about any medication, and he’s not going to.”
NOTE: Make sure that you always clearly understand the reasons for starting/stopping/changing prescription drugs before you and your physician make decisions together.
Dr. Mandrola sums up this situation nicely when he urges his colleagues to embrace the concept of deprescribing:
“I know what you may be thinking: rarely is it a good idea to substitute a big word, deprescribe, when a small one, like STOP, would do.
“It’s more than just an action; it’s a way of thinking, a mindset. It brings to the fore another important verb (and noun) – ‘need’.
“What do patients need? And who determines this need? How do needs change over time? The act of deprescribing offers an opportunity to inject care back into healthcare.”
Not all physicians are as open to the concept of deprescribing as the ones I’ve quoted here. So if yours has not yet brought up the subject with you, consider the sound advice of Alan Cassels, who suggests that patients should feel comfortable raising the question with their health care providers:
“It’s about reminding yourself that sometimes you have to be the first one to say, ‘enough is enough.’”
And while you’re waiting to chat with your doctor, watch Bohemian Polypharmacy, a very clever parody of the Queen song written by the very clever Dr. James McCormack (one of the “medication mythbusters” at Therapeutics Education Collaboration in Vancouver) and performed with exquisite harmonies by the Victoria band, Aivia.
NOTE: Do NOT stop or start taking any medications without discussing the decision with your physician first.
(1) Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med 2010;170:1648-54
(2) David Le Couteur et al. Deprescribing. Australian Prescriber Vol. 34 No. 6 2011. December 1, 2011.
(3) Nieuwlaat R et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub4
Q: Have you and your physician discussed deprescribing yet?