A written tapering plan is desirable, especially for classes of medication that require slow tapering (eg opioids, benzodiazepines), to avoid a return of disease symptoms or withdrawal symptoms. A written tapering plan has the potential to optimise the patient’s quality of life by reducing medications that are no longer appropriate in their clinical context.3,8
Many studies have found the benefits of slow, appropriate reduction of inappropriate medicines in older people, particularly those living in RACFs.9,10 Many guides for slow structured withdrawal of targeted medicines have been published, including:
- Primary Health Tasmania’s Deprescribing resources: One of the most accessible and practical guides.3,8
- Canadian Deprescribing Group’s Medstopper: Useful deprescribing tool for health professionals. The Canadian Deprescribing Group also have deprescribing guidelines and an interest group.11
- The Evidence-based clinical practice guideline for deprescribing cholinesterase inhibitors and memantine has been developed by the University of Sydney, in conjunction with the Bruyère Research Institute.12 The guideline contains seven recommendations that reflect the current evidence about when and how to trial withdrawal of cholinesterase inhibitors and memantine. The recommendations were approved by the National Health and Medical Research Council (NHMRC) in October 2017, and are directed at healthcare professionals. An algorithm was also developed to assist healthcare professionals in deprescribing.
Table 1 includes some medicines that require care when ceasing.
Examples of ceasing medications in older people 1,3,13,14,15
Potential barriers to deprescribing
While many patients may be willing to try ceasing medicines, some barriers may exist from a patient perspective, including:1,3,15,16
- anxiety and fear of consequences of stopping a medicine that has been prescribed for a long period
- reluctance to stop a drug when a patient believes it may prolong life or improve function
- previous negative experiences with drug withdrawal
- the perception that deprescribing suggests that the patient is ‘not worth treating’.
Medical practitioners may also find deprescribing challenging for several reasons, including:1,3,17
- adherence to disease-specific guidelines, which usually do not consider multimorbidities (refer to Part A. Multimorbidity)
- concern about ceasing medicines that another prescriber started
- time constraints
- fear of drug withdrawal syndromes or disease relapse
- difficulty in conducting life expectancy/quality-of-life discussions.
Shared decision making
All prescribers, patients and their family, pharmacists, nurses and allied health professionals are crucial components of deprescribing. It is important to explain to the patient that deprescribing is a positive intervention aimed at improving quality of life, and ensuring they do not receive unnecessary medicines with unlikely benefit or potential for harm. Individual potential risks, benefits and the withdrawal plan should be clearly explained, and patient or family concerns about deprescribing should be addressed.1,15,18
Patient involvement throughout the process is important to determine if care goals are being met and, if there are any adverse effects, medical practitioners should reinforce that deprescribing is part of an active treatment plan.
Developing a deprescribing plan
- assessing the patient to establish goals of care
- obtaining a comprehensive medication history
- identifying medicine/s that may be appropriate to cease
- prioritising medicine/s that should be ceased first
- developing a cessation plan
- monitoring and documenting outcomes after each medicine has been stopped.
Step 1. Review all medicines
It is important to review all of the patient’s medicines:1,19,20,21
- Review and reconcile medicines with other medicine lists, including those from a Home Medicines Review (HMR) or Residential Medication Management Review (RMMR), patient medicine list or discharge summary, with your current medicine list in your record.
- Check with My Health Record.
- Discuss any differences found with the patient, carer, RACF.
- Update the current medicine list.
Step 2. Assess and discuss
Assess medicine-related benefits and risk of harm, and discuss options with patient, resident, family and advocate:1,19,20,21
- number of medicines used
- high-risk medicines
- past or current toxicity
- patient/resident individual circumstances and preferences.
- Ask patient, resident, family and advocate if they are aware of, and understand, their options.
- Explain probable outcomes of continuing or discontinuing medicines, considering
- patient’s age
- cognitive ability
- dexterity problems
- other prescribers
- past or current adherence.
Step 3. Assess and consider
Assess and consider the ongoing need for each medicine via the following steps:1,19,20,21
- Step 3A. Medicine adds no benefit, due to
- no indication
- diagnosis no longer being appropriate
- cascade prescribing.
- Step 3B. Harm outweighs benefits
- Is anticholinergic load high?
- Step 3C. Symptoms or disease medicines
- Do guidelines suggest withdrawal after a period of stable disease?
- Step 3D. Preventive medicines
- Is the potential benefit of the medicine unlikely to be realised because of limited life expectancy?
- Step 3E. Continue medicine
Step 4. Prioritise medicines to be changed
Prioritise medicines that need to be changed by:1,19,20,21
- discussing, prioritising and planning any changes with patient, family and advocate
- asking them what they want
- deciding and agreeing on specific medicines to change, generally one at a time, slowly over weeks or months, in a stepwise approach.
Step 5. Implement and monitor
Implement the plan and monitor the patient as follows:1,19,20,21
- Initiate the changes in collaboration with patient, family and advocate.
- Highlight any withdrawal syndromes and taper doses where appropriate (refer to Table 1).
- Monitor and check any changes associated with stopping the drug.
- Develop a medication management plan with the patient, family and advocate (refer to Part A. Medication management ).
- Communicate the plan to the nursing staff, carers, accredited pharmacist, community pharmacy and your patient.