by Carolyn Thomas ♥ @HeartSisters
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 what 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 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.
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.”
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 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 drugs they’d been prescribed for high blood pressure 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 even 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.
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.
The single most important predictor of inappropriate prescribing and risk of adverse drug events is the number of prescribed drugs already 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 one of his Common Ground columns, 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. And ask your local pharmacist the same question.
Dr. David Le Couteur, the Australian 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 own heart patients, asking 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
NOTE FROM CAROLYN: I wrote more about common cardiac meds (and managing side effects) in my book “A Woman’s Guide to Living with Heart Disease“. You can ask for it at bookstores (please support your local independent bookseller) or order it online (paperback, hardcover or e-book) at Amazon – or order directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Q: Have you and your physician discussed deprescribing yet?
“I’m just not a pill person” – and other annoying excuses
Confessions of a non-compliant patient
Why don’t patients take their meds as prescribed?
Medical journalism watchdog slams cardiac ‘polypill’ news hype
17 thoughts on “Deprescribing: fewer drugs, better health outcomes?”
Such a hugely important topic. What I see so often with my homecare patients is cascade of prescriptions — a new drug prescribed to address what may be side effects of a previous drug or drugs, without ever re-considering the combined effects of all of them.
There is a pharmacy degree program here at our local university, and one of the best things the faculty had done is to offer a free medication evaluation and management service, where a pharmacist meets with a patient to evaluate all her meds and facilitates communication with her physician to see if her polypharmacy may be reduced.
Then there is the whole issue of the prudence of spending more time trying to help a patient make lifestyle changes that might be even more effective, rather than just prescribing yet another pill to ‘fix’ something… Oy.
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So many important points, Kathi! I’ve heard (anectodally) so often about taking Granny off her entire fistful of meds only to find that her ‘dementia’ went away. A medication review is such a great idea and should be a mandatory part of good medical care. And lifestyle changes? Often the most effective yet least prescribed “therapy” – and often we patients are the culprits themselves if we expect to leave the doctor’s office with a new prescription for what ails us…
Terrific post on a very important topic! I think deprescribing is hard for doctors to address for a number of reasons… it takes time and energy and often they are reluctant to “rock the boat.”
But it’s certainly important to reassess the need and dosage of all medications. For older people, the risks often increase over time, because people become more susceptible to side-effects and may be taking more medications over time.
We are moving towards regular high-quality medication reviews becoming the norm, but in the meantime there is no substitute for patients and families being proactive and making sure they’ve asked about all medications, and whether changes should be considered.
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Thanks so much for weighing in here, Dr. K. Regular high-quality medication reviews of all meds being prescribed are important for all patients, but ESPECIALLY as we get older, as you say, when we start taking meds to address the unpleasant side effects of all those other meds.
I hear women complain about their medications all the time, always threatening or saying that they have or will stop taking this or that. Always saying that they feel better and don’t think that they need them anymore.
“Did you ever think that you feel better BECAUSE you take the meds?”
I’m not a fan of big pharma but I’m alive because of the meds I take. My docs do review everything I take at my appointments, but the changes in the last 4 1/2 years have been minimal.
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Good point, Eve. I’ve heard women say they’re going to quit taking their antiplatelet drugs, for example (the bruises! the nosebleeds!) which could be a dangerous move for heart patients because of the high risk of restenosis inside a newly-implanted stent.
That’s why I urge everybody to talk to their physicians first BEFORE making any arbitrary changes to their meds.
And unless they’re specifically for pain, infection, nausea, etc, many of the drugs we take do not make us “feel better”. My larger concern about polypharmacy is, as in the examples I mentioned, the heart patient with normal blood pressure who is inexplicably put on drugs to lower her BP.
I’m wondering whatever happened to “First, do no harm”? Some of these thoughtless, ‘one size fits our protocol’ prescriptions do actual harm.
Maybe it’s because some of us are sent to specialists for everything, the specialists prescribe what they think we need, and the primary doesn’t review or feel she should review.
I’m thinking the payer – Medicare in the States in my case – should INSIST on a review, but then they will be accused of being ‘death panels’ and trying to save money.
It’s a mess, and only educated, concerned patients figure their own cases, or maybe their parents’ cases, out. The rest either stop taking drugs randomly, or continue taking too many. It takes time to do this analysis, and there is no diagnostic code it can be charged under.
The husband takes 8-10 drugs a day, has peripheral neuropathy, and refuses to listen to me when I tell him several of those drugs had the neuropathy as a side effect. Instead, the neurologist keeps insisting the neuropathy MUST be because of pre-diabetes (it’s the only cause of peripheral neuropathy he recognizes), and added drugs for something husband doesn’t have, on test after test. I throw my hands up.
Although my primary sent me to the ER after she did an EKG on me, I only let the cardiologist prescribe my drugs. My primary is fine with it and even if she wasn’t, I still would insist that the cardiologist prescribe since that is my only health issue. I was able to have him take me off Lipitor, cut my Amlodipine and my Lisinopril in half. Also, I kept telling him that Coreg was one of my biggest problems and he kept cutting until he finally had me stop. My heart rate was going in the high 30’s low 40’s I could hardly function I was so tired. I am on Digoxin, but the very lowest dose you can take.
I think it is important that you speak up and the doctor listens when you tell them these drugs are not helping and making you feel worse. I am a compliant patient, though. When he said no alcohol, smoking, low sodium diet and 30 mins of exercise everyday, I listened to him and did it. Maybe it is a two way street: you listen and comply and then they listen – or I am just damned lucky with my cardiologist?
It amazes me the number of people who take so many drugs and don’t know what they take or why they were put on them. I ask what will this medicine do for me, what happens if I don’t take it. Thanks for a great article.
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I’m with you, Michelle! I’m always amazed when people have no clue about what they’re taking or why. My late Mum used to refer to her hefty collection of confusing daily pills as simply “the pink ones” or “the big yellow ones”. (I wrote about this kind of blissful ignorance in “Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them“)
I think you’re so right when you say: “Maybe it is a two way street: you listen and then they listen!” Two-way listening may not be a 100% guarantee all the time, but it has to be far easier when both members of a health care partnership team are doing their best to listen.
I came across this very interesting blog by a cardiologist who has interesting perspectives on the kinds of issues which relate to those you write about so well.
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Thanks for the link to that intriguing article, Anna. The author’s statement “Doctors are rarely comfortable when patient ask probing questions” seems quite applicable to my post here on deprescribing; some docs may be understandably reluctant to have their choice of recommended meds up for discussion. As cardiologist Dr. Mandrola is quoted in this post: “The act of prescribing lies at the core of what doctors do to help patients.” It’s such a longstanding and fundamental part of doctoring.
Thanks for this article. I agree with the thrust of it and I have every sympathy with those who feel over-medicated, but like you I urge great caution when stopping meds.
My experiences have lead me down a different path than most people and I am no longer able to take what any doctor or cardiologist says on face value. I think that a having a belief in one’s prescriber and the pills they give is crucial to their efficacy too.
Despite having a heart attack and heart disease, I have felt alienated from the heart disease community, not because anyone is unpleasant, but because I am not and cannot be med compliant.
I stopped quite a number of prescription meds abruptly ( cold turkey ) in 2008. I was unprepared for what happened next; I nearly died. It was extreme and suffice it to say I never recovered my health, and I have been left with a frightening tendency to take extreme reaction to meds and supplements
Next came the heart attack and the unenviable position of taking adverse reaction to the prescribed drugs.
Like you Carolyn, I was also left with a lot of pain and “heart attack ” symptoms and was offered meds to deal with them. The reactions are often more terrifying than the disease itself. I had to refuse to take the pills and just get on with it.
My problems began because I was over-medicated in the first place and I am now having to go it alone on a minimum of meds relying on diet and what exercise I can do.
Well so far .. I appear to be still alive and kicking … as it turns out, there seem to be viable herbal alternatives for lowering cholesterol, supporting heart function and herbs with a beta blocker action and it would appear with very few of the unpleasant and potentially unhealthful side effects! I take what I can of those … but it’s based upon my own research.
I was disappointed to learn that cardiologists did not really know very much about these treatments, which is a bit odd as they pre-date statins, beta blockers and the rest .
I have had to close my mind to articles about the alleged dangers of non-compliance of what I was initially prescribed.
I really feel those who advocate that one must be on a drug for life must have a vested interest in keep us unhealthy. As far as I know, one builds up a tolerance to most drugs. I know this is the case with psychoactive drugs and I don’t see why it would be different with anything else. I was like so many people I just took the pills that were offered ..and more and more were offered until I became sick. I have sort of dropped out of the system as it no longer works for me. I know I have drifted way off topic, but this article resonated with me so much.
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Your story seems to reinforce the importance of HOW to stop/taper specific meds even when over-medication is an issue, Gillian (e.g. NOT cold turkey and NOT without being carefully monitored by one’s health care team over an appropriate length of time to prevent what happened to you). You seem like a patient who is quite deliberately “non-compliant” (arrrgh – I hate that term!) and a good example of why things like flashing digital pillbox reminders simply do not work on so many patients who for MANY REASONS stop taking their meds – no matter how all the tech hype tries to convince us. See also: “Why Don’t Patients Take Their Meds As Prescribed?“
I think that the best example of a cardiac drug linked to building up tolerance is the well-known vasodilator, nitroglycerin (my own personal favourite don’t-leave-home-without-it drug!) Even those wearing nitro patches to treat the intractable chest pain of angina must take overnight breaks from the patch in order for these meds to continue working effectively…
PS. I got your second message and YES I did write all of the other posts listed at the end of this post! 😉
Gillian stated she had left the loop, and why; all good reasons. You write, Carolyn – “…being carefully monitored by one’s health care team.” How many of us are started on medications without necessary pre-testing, or an iota of “team” integration to ensure that other dis-eases within us should prohibit one drug over another, or entirely.
How many patients are actually monitored at regular intervals once they begin a new drug. I know I haven’t been, even when I have “insisted.” I won’t be given an appointment. Basically, it’s shunning. Interesting professional way to handle it, eh?
In reference to my discontinuance of a drug, I cannot emphasize strongly enough that the cardiologist, (and primary care physician), have the “just stop taking it” mantra.
I am sorry that, in another comment, the reader becomes defensive. No one has said that anyone must stop, lessen, or do anything at all about the drugs they are being prescribed. Personally, I never hear women complain about their medications, but I guarantee it’s because they can’t get the answers, the follow-up, etc., they should be receiving. Why attack other women? Keep taking your medications; no one is suggesting that you don’t. Great that you feel better with them than without them.
Thank you, Carolyn, for the article.
I see my cardiologist once a year and my GP every three months to renew my prescriptions and for an annual physical complete with blood tests (fasting), the results of which are faxed to the cardiologist at my request. Every time the cardiologist has recommended a drug be dropped or the dosage reduced, my GP has initially demurred – on the grounds that “it’s too early” or that the cardiologist “goes on the basis of research reports; I treat actual people.”
In every case, she has eventually agreed to the cardiologist’s suggestion, but only with a 6 to 12 month lag. Recently, however, she substituted bisoprolol (one daily) for the cardiologist’s metroprolol (twice daily) on the grounds that (a) it’s a better medication, and (b) you only have to take it once a day – who’s to know? Not I, so I await the opinion of the cardiologist. I sense both professional jealousy, conservatism, and a fear of liability at work here on the part of the GP. The cardiologist, for his part, is generally happy with my progress, especially the results of the blood work.
So deprescription is eventually happening, but slowly. (As a patient, I hate being caught between the two, trust both of them, and hold my tongue.)
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Ooooh, duelling prescribers. . . It’s discouraging to suspect that “professional jealousy, conservatism, and a fear of liability” may be factors here. They should not be so. Thanks for this, Judy.