Review of structured guides for deprescribing

Abstract

Avoiding inappropriate polypharmacy has become increasingly recognised as a safety imperative for older patient care. Deprescribing is an active process of reviewing all medications being used by individual patients that prompts clinicians to consider which medications have unfavourable risk–benefit trade-offs in the context of illness severity, advanced age, multi-morbidity, physical and emotional capacity, life expectancy, care goals and personal preferences. Structured guides to deprescribing include algorithms, flow charts or tables which are patient-directed and aim to guide the clinician through sequential steps in deciding which medications should be targeted for discontinuation. In this narrative review, we describe seven structured deprescribing guides whose stated purpose included the reduction of polypharmacy, their use was not restricted to a single drug or drug class and they had undergone some form of efficacy testing. There was considerable heterogeneity in guide design and content, with some guides constituting little more than a set of principles while others entail detailed processes and sub-steps which addressed multiple determinants of drug appropriateness. Evidence of effectiveness for each guide was limited in that none have been evaluated in randomised controlled trials, that pilot or feasibility studies have involved relatively small patient samples, that intra-rater and inter-rater reliabilities have not been determined and that most have been studied in hospital settings. Which is most useful to clinicians is unknown in the absence of head-to-head comparisons. While most guides have face validity, more research is needed for determining effectiveness and ease of use in routine clinical practice, especially in primary care settings.

Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice

“…Many generic (non‐drug specific) deprescribing frameworks have been published . These often provide a stepped approach to deprescribing, highlighting that it is a process (rather than a simple one‐off interaction).…”

Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review

“…Therefore, it is unclear whether using these tools is likely to result in a meaningful reduction in inappropriate medication use and improve outcomes, or even cause harm . A previous review also noted this limitation . Lack of clinical outcome data and inconsistency in outcome measurement have also been highlighted as limitations in deprescribing studies .…”

“…A 2018 systematic review evaluating deprescribing interventions in older persons found that few studies measured clinical outcomes and that none were adequately powered to detect differences in clinical outcomes between intervention and control groups . A number of deprescribing tools have been developed in recent years, but they remain largely untested . Researchers and clinicians should focus on developing quality tools using systematic and explicit methods.…”

“…We used a systematic search to identify tools, with two authors screening and all authors approving final study selection. The systematic, up‐to‐date search allowed us to identify tools not summarized in previous reviews, and thus there was little overlap . By focusing our review on tools applicable to frail older persons and individuals with limited life expectancy, we provide insight into the tools most applicable to this population.…”

“…The range of tools available to support deprescribing was summarized in 2012 and 2017 (search conducted December 2015), but neither review focused specifically on frail older persons or those with limited life expectancy. Although deprescribing is important to consider at all stages of medical care, it is particularly important in frail older adults and those with limited life expectancy for the reasons outlined above.…”