Deprescribing: how to decide what to stop with the patient

An 83-year-old man arrives for a routine appointment with a bag of medicine boxes. There are nine medications, prescribed over fifteen years by four different professionals. Some he has taken for so long that he no longer knows what they are for. He says he has been more tired, that he felt dizzy twice in the last week, and asks, almost apologizing, whether it would be possible to stop taking one of them.

Situations like this are common in primary care, and the answer is rarely simple. Stopping a medication can relieve adverse effects and the burden of treatment, but it can also bring back symptoms or increase a risk that was under control. Deprescribing is the name given to the process of making this choice methodically. This text presents the definition used in the research, the proposed steps, how to choose what to remove first, how to talk with the patient, and what the evidence shows about the results.

Key points

• Deprescribing is the planned and supervised withdrawal of an inappropriate medication, with the goal of reducing polypharmacy and improving outcomes.
• The number of medications in use may be the main single predictor of adverse drug effects.
• The process has steps: review everything the person uses, identify what may be inappropriate, decide what to remove and in what order, plan the withdrawal and follow up.
• Most older people accept stopping a medication if the doctor says it is possible, but fear and the lack of a clear plan get in the way.
• On the prescriber's side, the barriers include inertia, insecurity, lack of time and fragmented care among several professionals.
• Deprescribing reduces the number of medications safely; the effect on mortality appears mainly when the intervention is individualized.

Summary

• What deprescribing is
• Why deprescribe
• The steps of the process
• How to choose what to remove first
• The conversation with the patient
• Barriers on the prescriber's side
• Following up the withdrawal
• What the evidence shows
• Frequently asked questions
• Final checklist

What deprescribing is

The term has appeared in the literature since the early 2000s and, for a long time, each group used it in its own way. A systematic review located 231 articles on the topic and found 37 with some definition. The characteristics found included the idea of stopping or withdrawing a medication, the focus on long-term or inappropriate treatments, the use of the word process, the planned and supervised nature, the existence of several steps and the possibility of reducing or substituting instead of stopping (Reeve, 2015).

From this analysis, the authors proposed a working definition: deprescribing is the process of withdrawing an inappropriate medication, supervised by a health professional, with the goal of managing polypharmacy and improving outcomes (Reeve, 2015). Three elements of this sentence deserve attention. The first is the word process: it is not an isolated act. The second is supervision: the withdrawal is monitored, not left to chance. The third is the goal: the aim is not to use fewer medicines for its own sake, but to improve the person's health.

This definition separates deprescribing from two similar situations. One is stopping on one's own, when the patient stops a medication without talking to anyone. The other is reactive discontinuation, when the clinician removes a medicine after an adverse effect has already occurred. Deprescribing is proactive: it looks for the medication that no longer makes sense before it causes harm.

In primary care practice, it is often the natural continuation of a review of the treatment as a whole. When the clinician and the person define what matters most to them, some medications no longer have a place. The next step is to decide how to remove them safely.

Why deprescribe

Inappropriate polypharmacy, especially in older people, is associated with adverse events, worsening health, disability, hospital admissions and even death. A systematic review on deprescribing in older people living in the community notes that the number of medications a person uses may be the main single predictor of adverse effects (Bloomfield, 2020).

This fact has an important consequence. Each added medication may be defensible on its own, but the risk grows with the whole set. Dizziness, falls, confusion, loss of appetite and fatigue often result from the sum of several treatments, not from just one. In older people, a fall from standing height can have serious consequences, as the text on trauma in older adults discusses, and delirium has medications among the causes to look for.

There is also prescribing cascade: an adverse effect is interpreted as a new disease and treated with one more medication, which in turn brings new effects. Without periodic review, the list grows on its own. Often none of the professionals involved has the full picture, because each one prescribes within their own area.

Finally, the original indication may have changed. A medication started ten years ago to prevent a distant event may have little value for someone who today has other priorities and less time to reap the benefit. The reasoning about expected benefits and harms needs to be redone as the person ages and their goals change. Keeping a treatment with no likely benefit is also a form of excess, related to what is discussed about overdiagnosis.

The steps of the process

The scripts proposed over the years are similar. A review of earlier processes recovered five principles published back in 2003 (Reeve, 2014):

• review all medications in use;
• identify those that may be targets for stopping;
• plan a withdrawal schedule;
• plan in partnership with the patient and their caregivers;
• review often and give support.

From this review and from what is known about patients' views, the same authors proposed a patient-centered process. It forms a cycle of five steps, which begins with a complete medication history, goes through identifying potentially inappropriate ones and deciding whether each can be withdrawn, continues with planning the withdrawal, gradual when necessary, and ends with monitoring, support and recording (Reeve, 2014). The authors stress that the patient should take part in all the steps (Reeve, 2014).

Step	Practical question	What to observe
Complete review	What does the person actually use, who prescribed it and for what?	Include medicines from other professionals, without a prescription and of occasional use
Individual risk	How vulnerable is this person to adverse events?	Number of medications, age, frailty, kidney and cognitive function, recent falls
Assessment of each item	Does the expected benefit still outweigh the harm and the burden?	Current indication, the person's goals, time for the benefit to appear
Priority	Where to start?	Worst balance between benefit and harm, lowest risk of rebound, the person's preference
Plan and follow-up	How to withdraw and how to know whether it worked?	One change at a time, gradual withdrawal when indicated, warning signs and return date

The table sums up the two scripts in a single sequence. It does not replace clinical judgment, but it helps avoid two common mistakes: withdrawing something without knowing why it was started, and withdrawing several medications at the same time, which prevents knowing which change caused an effect.

How to choose what to withdraw first

The prioritization step is the hardest to standardize. Identifying a medication as potentially inappropriate does not mean it can be withdrawn at that moment, and often only follow-up after the attempt shows whether it had a benefit for that person (Reeve, 2014). When there is more than one candidate, the patient-centered process recommends withdrawing them in sequence, not together, to know which change caused a withdrawal reaction or the return of the disease (Reeve, 2014). When choosing the first one, it makes sense to look at treatments with no clear current indication, at those that cause or may cause the symptoms the person complains about, and at those that demand a lot of effort for a small benefit.

The individual risk sets the pace. A frail person with many conditions and recent falls calls for a broader and faster review. A person with good function and few medications can have a more targeted review. Timing also matters: the person should be stable, so that a new symptom can be attributed to the withdrawal, and the attempt should happen when a possible return of the disease would have little impact on their life (Reeve, 2014).

The person's preferences also come into play at this point. Patient and physician priorities may differ, and the authors suggest discussing them until reaching agreed goals (Reeve, 2014). Sometimes the medication with the worst theoretical balance of benefit and harm is precisely the one the person values most, and starting with another item can build the trust needed for bigger changes. The opposite also happens: the person may ask to stop a medicine that bothers them a lot, even if it has relevant benefit, and the conversation needs to clarify what is lost and what is gained.

Some medications require slow withdrawal, because abrupt discontinuation can cause withdrawal or rebound symptoms. The text on the pace of reduction shows how that pace is decided with the patient, not by formula. The same logic applies to other withdrawals: the plan needs to be specific to the medication and to the person.

The conversation with the patient

Primary care physicians often cite patient resistance as one of the main barriers to deprescribing. A population survey of 1,981 people aged 65 or older showed a different picture: about nine in ten said they would accept stopping one or more medications if the physician said it was possible, and about two in three said they would like to reduce the number of medicines (Reeve, 2018). Those using six or more medications were more willing to stop and to reduce.

This does not mean the conversation is easy. Stated willingness in a survey can be much greater than actual willingness when faced with a concrete proposal, and among the main barriers on the patient side are fear of the consequences and disagreement that the medication should be stopped (Reeve, 2014). Trust in the relationship with the physician influences willingness to stop, and having a clear plan for withdrawal is decisive for the person to agree (Reeve, 2014).

The same review gathers approaches to increase patient willingness (Reeve, 2014):

• present deprescribing without provoking fear or undermining the relationship with whoever prescribed it;
• make clear that the proposal seeks the goals of treatment, not that the person does not deserve to be treated;
• discuss the lack of benefit or lack of need for the medication and the risks of keeping it;
• explain what will be done to reduce the risks of withdrawal and confirm that it is a trial.

In the consultation, this means linking the withdrawal to something the person values, such as less dizziness or fewer pills, asking who else takes part in their health decisions and acknowledging the fear, which is legitimate, especially when the medication was presented in the past as indispensable. The text on how to open the conversation without a label offers examples of language that are also useful in other withdrawals.

It is also worth noticing what the person brings up without being asked. Complaints such as fatigue, dizziness or forgetfulness can be effects of the medications themselves, and the clues the patient offers during the consultation often reveal discomfort with a treatment before any direct question. Since the review usually competes for space with other subjects, mapping the agenda before investigating helps set aside time for it, or schedule a visit just for that. A dedicated consultation, with the bag of medicines on the table, usually yields more than several minutes stolen at the end of an appointment for another reason.

This is a form of shared decision-making. When there is cognitive decline, it is worth assessing decision-making capacity and including family members or caregivers without taking away from the person what they can still decide. In people with advanced disease, the conversation about preventive medications is often part of advance care planning.

Barriers on the prescriber side

If most patients accept stopping, why is deprescribing still rarely practiced? A review of 21 qualitative studies, most with primary care physicians, organized the barriers and facilitators into four themes (Anderson, 2014). The first is awareness of the problem: the prescriber needs to realize that a medication has become inappropriate. The second is inertia, because continuing seems to have more value or less risk than stopping. The third is self-efficacy, confidence in one's own ability to change the prescription. The fourth is feasibility in the routine, limited by external factors such as time, the health system and patient expectations.

A more recent review gathered 40 studies from 14 countries on deprescribing in adults with multimorbidity and polypharmacy in primary care (Doherty, 2020). Among the cultural and organizational barriers were the culture of diagnosing and prescribing, guidelines centered on a single disease, lack of evidence-based guidance for older adults with several conditions and absence of shared communication and decision systems. Among the interpersonal and individual barriers were professional etiquette, which appears, for example, in the reluctance to stop what another specialist started, fragmented care and the uncertainty of prescribers and patients.

The facilitators identified by the same review were prudent prescribing, non-pharmacological alternatives that are more available and accepted, adequate resources, better communication and collaboration among professionals, person-centered care and shared decision-making (Doherty, 2020). Many of these factors depend on how the service is organized, and not only on the clinician's individual effort.

Automatic prescription renewal is a concrete example of inertia: each renewal is a clinical decision, even when it looks like an administrative act. Cognitive biases also weigh in. The fear of being held responsible for an event after withdrawal is usually greater than the discomfort with the silent harm of keeping a treatment without benefit, as discussed in the text about biases that get in the way of tapering.

Following up on the withdrawal

The last step of the patient-centered process brings together monitoring, support and recording (Reeve, 2014). The authors note that there is little evidence on how to do this follow-up, that the type and duration depend on the medication and the person, and that most patients prefer an in-person visit at least at the first return after stopping (Reeve, 2014). Recording the outcome, with what was stopped or reduced and why, helps avoid errors and the restarting of medications already withdrawn (Reeve, 2014).

In practice, following up means agreeing with the person, before any withdrawal, which signs justify coming back earlier than planned, when the next assessment will be and what will be observed. Withdrawing one medication at a time allows a change to be attributed to the right withdrawal. Recording it in the medical chart, with the reason for the decision and what was agreed, prevents the medication from being automatically restarted by another professional who does not know the history.

The team helps at this step. Nursing and pharmacy can check how the person is using the medications after the change, notice difficulties with organization and identify early signs of poorly tolerated withdrawal. Family members and caregivers also need to know what changed, so they do not mistakenly offer the withdrawn medicine or interpret a passing symptom as a reason to restart everything on their own. The clearer the communication among everyone, the lower the chance that the list grows again without anyone noticing.

This follow-up has a lot in common with the planned reassessment used in the face of diagnostic uncertainty. Instead of a definitive decision, the withdrawal becomes a test with a date for review. If symptoms return, restarting the medication is not a failure: it is information that confirms it had a function for that person.

Withdrawal with follow-up also seems feasible in those who are most vulnerable. A systematic review on deprescribing in frail older people found only six studies, two of them randomized, with 657 participants (Ibrahim, 2021). In the studies that measured feasibility, between about seven and nine out of every ten withdrawal recommendations were implemented, and the three that assessed safety showed no significant change in adverse events, hospital admissions or mortality (Ibrahim, 2021). The authors acknowledge that the evidence is still scarce and heterogeneous.

What the evidence shows

A systematic review with meta-analysis gathered 132 articles and 34,143 older participants (Page, 2016). In non-randomized studies, deprescribing was associated with lower mortality, but this effect was not confirmed across the randomized studies. In the subgroup analysis, however, individualized interventions, planned for each patient, reduced mortality in the randomized trials, while general educational programs had no such effect.

Another review, restricted to people aged 65 or older living in the community, included 38 clinical trials (Bloomfield, 2020). Thorough medication review may have reduced mortality, with low certainty, but probably had little or no effect on falls, quality of life and hospital admissions. Educational interventions reduced the use of potentially inappropriate medications, with little or no effect on the main outcomes.

In long-term care facilities, a randomized trial with 95 residents tested the planned withdrawal of medications without benefit (Potter, 2016). Of the 348 medications selected, 207 were successfully withdrawn. Over twelve months, the average number of medications fell by 1.9 in the intervention group and rose by 0.1 in the control group, with no significant adverse effect on survival, falls, fractures, hospital admissions or other outcomes (Potter, 2016).

In primary care, a cluster-randomized trial with 21 practices and 196 patients tested an intervention with pharmacist support, medication review using algorithms and informational material for patients (Clyne, 2015). At the end, the intervention group had a lower chance of potentially inappropriate prescribing, with an average of 0.70 inappropriate medication per patient versus 1.18 in the control group (Clyne, 2015).

It is worth noting what these studies do not show. None of them indicates that withdrawing medications indiscriminately is safe, and almost all worked with careful reviews, done by trained professionals and with follow-up. The safety observed is that of planned withdrawal, not that of suspension without criteria.

Taken together, the studies show that deprescribing reduces the number of medications and the use of inappropriate medications, apparently without increasing harm. The effect on hard outcomes is less clear and seems to depend on interventions tailored to each person, which reinforces the idea that deprescribing is a clinical act, not a rule to apply across the board.

Frequently asked questions

Is deprescribing the same as stopping a medication?

No. Deprescribing is a planned and supervised process that includes review, decision, withdrawal and follow-up, with the goal of improving outcomes (Reeve, 2015). Stopping on your own or only after an adverse effect is not deprescribing.

Where should the review start?

With the complete medication history, the first step of the patient-centered process (Reeve, 2014). It is worth including those prescribed by other professionals, those without a prescription and those used occasionally, with the reason for each one. Asking the person to bring all the boxes to the appointment often reveals surprises.

Will the patient feel abandoned if I take away medications?

Most older people accept stopping a medication when the doctor says it is possible (Reeve, 2018). Explaining the reason, presenting a plan and scheduling a follow-up visit helps convey care, not abandonment.

Can I withdraw several medications at the same time?

In general, it is safer to stop one at a time, so you know which change caused each effect. The exception is situations where the risk of continuing is high, and the decision should be individual.

What if the symptoms come back?

The medicine can be restarted. In some people, the return of symptoms confirms that the medicine was necessary, and stopping it gradually helps distinguish a withdrawal reaction from the return of the disease (Reeve, 2014). Restarting, in this case, is useful information, not a failure.

Does deprescribing reduce mortality?

The evidence is mixed. Individualized interventions reduced mortality in randomized trials, but general programs did not (Page, 2016). The most consistent gain is the safe reduction in the number of medicines.

Final checklist

• Gather the complete list of medicines and the reason for each one, including those from other professionals.
• Estimate the individual risk of harm from medicines to define how intensive the review should be.
• Compare benefit and harm of each item in light of the person's current goals.
• Start with the medicines that have the worst balance between benefit and harm and the lowest risk of rebound.
• Explain the reason, present a concrete plan and acknowledge the fear of stopping.
• Stop one medicine at a time, agree on warning signs and a return date, and record the decision.

References

1. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014. PMID 25488097. DOI 10.1136/bmjopen-2014-006544.
2. Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med. 2020. PMID 32820421. DOI 10.1007/s11606-020-06089-2.
3. Clyne B, Smith SM, Hughes CM, et al. Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study). Ann Fam Med. 2015. PMID 26553894. DOI 10.1370/afm.1838.
4. Doherty AJ, Boland P, Reed J, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open. 2020. PMID 32723784. DOI 10.3399/bjgpopen20X101096.
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7. Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in Frail Older People: A Randomised Controlled Trial. PLoS One. 2016. PMID 26942907. DOI 10.1371/journal.pone.0149984.
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9. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014. PMID 24661192. DOI 10.1111/bcp.12386.
10. Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med. 2018. PMID 30326004. DOI 10.1001/jamainternmed.2018.4720.