Methodology for Developing Deprescribing Guidelines: Using Evidence and GRADE to Guide Recommendations for Deprescribing

Abstract

BackgroundClass specific deprescribing guidelines could help clinicians taper and stop medications no longer needed or which may be causing more harm than benefit. We set out to develop methodology to create such guidelines using evidence-based methods for guideline development, evidence synthesis and recommendation rating.Methods and FindingsUsing a comprehensive checklist for a successful guideline enterprise, we conducted a national modified Delphi consensus process to identify priorities for deprescribing guidelines, then conducted scoping exercises to identify feasible topics, and sequentially developed three deprescribing guidelines. We selected guideline development team members for clinical expertise; a GRADE member worked with staff to ensure guideline development processes were followed. We conducted or used systematic searches and reviews of deprescribing trials of selected drug classes, reviews or systematic reviews of drug class effectiveness, reviews of reviews of drug class harm and narrative syntheses of contextual questions to inform recommendations and guideline development. Our 8 step process for guideline development included defining scope and purpose, developing a logic model to guide the process and generate key clinical questions, setting criteria for admissible evidence and conducting systematic reviews, synthesizing evidence considering additional contextual information and performing quality estimates, formulating recommendations and providing strength estimations, adding clinical considerations, conducting clinical and stakeholder review and finally updating content pre-publication. Innovative aspects of the guideline development process included synthesizing evidence for outcomes of tapering or stopping medication, and incorporating evidence for medication harm into the recommendation strength rating. Through the development of three deprescribing guidelines (for proton pump inhibitors, benzodiazepine receptor agonists and antipsychotics) and associated decision-support algorithms, we were able to gradually hone the methodology; each guideline will be published separately.ConclusionOur methodology demonstrates the importance of searching for short and long-term outcomes, showing the benefits of deprescribing and studying patient preferences. This publication will support development of future deprescribing guidelines.

Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults

“…Additionally, guidelines for safe methods of deprescribing cardiovascular medications are also needed; guidelines for deprescribing other medication classes have been developed and could provide a useful starting point. [24][25][26] We found that barriers to deprescribing were diverse but consistent across specialties and largely consistent with prior surveys of primary care physicians' perspectives on deprescribing PIMs. 9,10,12 Importantly, interfering with another clinician's treatment plan was the most frequently reported barrier to deprescribing cardiovascular medications, extending observations from other countries.…”

“…Tools like the Screening Tool of Older Persons Prescriptions in Frail Adults With Limited Life Expectancy could assist clinicians with identifying cardiovascular medications that provide limited benefit. Additionally, guidelines for safe methods of deprescribing cardiovascular medications are also needed; guidelines for deprescribing other medication classes have been developed and could provide a useful starting point …”

Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project

“…19 Currently, deprescribing guidance is limited, with clinicians reporting difficulty in weighing the harms against the benefits of continuing or stopping medications. 29 PPIs were selected by OPEN as 1 of 3 medications for development of a deprescribing guideline to "support health care professionals taper or stop potentially inappropriate medications that may be causing harm or no longer providing a benefit as well as monitoring for potential adverse withdrawal effects". 28 At the time of the current study (late 2015 to early 2016), the OPEN algorithm had not yet been published.…”

“…Since then, the methodology for developing the OPEN deprescribing algorithms has been published (in August 2016). 29 Thompson and others 27 implemented and evaluated the OPEN PPI deprescribing algorithm at 3 residential care sites and found that it could decrease PPI prescribing. We used the algorithm to assess whether residents fit the criteria for discontinuation and then monitored those with PPI discontinuation to assess for recurrent gastrointestinal symptoms that would warrant re-initiation of the PPI.…”

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

“…The target medication is stopped and health outcomes are measured. These types of studies are essential for the development of drug-specific deprescribing guidelines [12] to provide guidance on when it is suitable to withdraw medications. They also have the benefit of measuring drug-specific outcomes including resolution of adverse effects or reduction of risk (e.g.…”