Background

Polypharmacy is defined as the act of taking five or more medications on a regular basis.¹ As discussed in another PSNet primer, polypharmacy is an often preventable risk factor for adverse drug events (ADEs). Current data suggest that the risk for experiencing an ADE is 88% higher among patients taking five or more medications compared to patients taking fewer than five medications.² Additionally, polypharmacy contributes to significant morbidity and mortality in the United States; results of one meta-analysis suggested that adjusted mortality among patients receiving five or more medications is 31% higher than among patients taking fewer medications.³

Many risk factors that contribute to polypharmacy have been proposed, and each serves as a potential area for intervention to avoid this practice. Some common risk factors, described in a 2019 article in American Family Physician,¹ are listed in Table 1 below.

Table 1. Common Risk Factors for Polypharmacy

Deprescribing is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use. Deprescribing is one intervention that can be applied to reduce the risk for ADEs or medication errors associated with polypharmacy. This practice should be considered any time a patient is experiencing polypharmacy and should be implemented using a shared decision-making model.⁴ Shared decision-making comprises patients and clinicians collaborating to discuss the appropriateness of each of the patient’s medications as it relates to safety and efficacy; it empowers the patient to be engaged in decisions about their care. There is extensive evidence demonstrating that use of this shared decision-making model improves patient outcomes and many documented examples in which engaging patients in their own care decisions led to those patients selecting more conservative treatment options.⁵

Strategies for Deprescribing

Multiple strategies and best practices can be employed to facilitate deprescribing and thereby improve patient safety. A useful way to approach deprescribing is to break it down into a five-step approach:⁶

1. Consider all medications currently being taken and the indications for each.
2. Evaluate the risk of harm to that individual patient associated with each medication.
3. Assess each medication for the potential to deprescribe it.
4. Create a priority list of medications that should be deprescribed before others.
5. Implement and monitor the deprescribing regimen.

To accomplish the first step, providers should perform a comprehensive medication review and reconciliation. Medication review and reconciliation is the process of developing an accurate and complete list of a patient’s current medications. Some of the benefits of medication reconciliation are discussed in another PSNet primer and demonstrated in a PSNet WebM&M case. A best practice when performing medication reconciliation is to use multiple sources of information, such as recent discharge notes, a patient’s home list, and/or a pharmacy fill history, to create the most accurate and up-to-date list possible.⁷

When deciding if a medication should be deprescribed, it is important to consider the purpose of each medication (curative vs. palliative), how the patient is tolerating the medication, the patient’s life expectancy and goals of care, and the time it will take to see benefit from the medication, among other things.⁸ Determining why each medication was started and how each medication is currently helping the patient can help providers with the deprescribing process by identifying any prescribing cascades or medications that may no longer provide benefit.

There are published tools available to assist with recognizing PIMs. Table 2 describes some of the features of three tools commonly used to assist with deprescribing. Many tools focus on the older adult population because these patients are more likely to experience polypharmacy. These resources, along with others, are also discussed in two previously published PSNet WebM&M cases, one focusing on a pill box utilization error and another on warfarin misuse.

Table 2. Tools for Deprescribing

For patients that have multiple medications being considered for deprescription, it is important to take a stepwise approach. Medications should be withdrawn one by one to allow for accurate evaluation of the outcome of each discontinuation, and medications given highest priority in step 4 of the 5-step process described above should be stopped first. The medication priority list should be created based on patient-specific factors assessed in previous steps, including any side effects the patient may be experiencing, the potential for harm from the medication, the potential for benefit from the medication, and the patient's motivation to stop and/or continue the medication, among other things. Some medications, such as opioids, benzodiazepines, and beta blockers, should not be abruptly stopped and need to be tapered slowly. Consult the prescribing information to review the pharmacokinetic and pharmacodynamic properties of each medication that is to be deprescribed to determine if tapering is necessary and to decide how long to wait before making another medication change. During the deprescribing process, it is important to document the reason for making the medication change as well as its outcome to support future decision-making related to the patient’s medication management.¹⁰ Furthermore, keep in mind that when a medication is discontinued in the electronic health record (EHR), this information is not automatically transmitted to the patient’s pharmacy. Therefore, a critical step when deprescribing is to communicate with the appropriate pharmacy to ensure the medication change is implemented.

There are also electronic clinical decision support systems (CDSSs) that may aid in deprescribing. One example is MedStopper, which is a web-based system that provides benefit and risk information for each medication on a patient’s list. It creates a recommended “Stopping List” for PIMs, provides recommendations about tapering, and describes possible withdrawal symptoms. This resource is publicly available and free to use.¹¹ Additionally, with advancements in the EHR and e-prescribing, incorporating CDSSs into the EHR at the point of care is an option. Utilizing EHR-enabled CDSSs has been shown to be effective in reducing the prescribing of PIMs in hospital settings.¹²

Finally, deprescribing is an ongoing process that requires monitoring and feedback. Various decision aids, pamphlets, and other resources are available to support this process.¹³ Because deprescribing may involve withdrawal symptoms or recurrence of symptoms that motivated the original prescription, re-initiation or dose adjustments may be necessary. Many patients see multiple providers and can re-accumulate medications despite deprescribing efforts, so ongoing discussions between primary care and specialty providers may be needed.¹⁴

Current Context

The practice of deprescribing has been assessed in multiple systematic reviews and meta-analyses.^15-17 Although the studies and patient populations included in these analyses vary, the findings often support the use of deprescribing. The benefits of deprescribing include reduced morbidity and mortality, improved quality of life, decreased hospital admissions, reduced falls, and improved mental status.

To successfully implement deprescribing practices in clinical settings, the Institute for Healthcare Improvement (IHI) suggests taking an iterative approach of gradual expansion.¹⁸ Their four-step model of implementation involves identifying current practices within a health system, establishing a data-driven goal for deprescribing that fits within the context of the prescribing culture of the health system, and implementing interventions to facilitate deprescribing at progressively larger scales over time. The IHI model encourages using narrowly focused interventions that can be gradually expanded into larger, more comprehensive interventions once deprescribing algorithms have been developed and tested in real-world patient situations. Throughout each step of the implementation process, the IHI Deprescribing Guideline stresses the importance of engaging key stakeholders, such as clinicians, pharmacists, informatics staff, and patients, to ensure not only successful implementation but also the longevity of the implemented changes. Although utilizing their model requires significant planning and testing in the early phases, the use of data-driven goals to guide design of deprescribing interventions will ultimately lead to improvements in health system metrics that will positively reinforce deprescribing practices. The IHI guidelines thus serve as a useful reference for health system administrators looking to develop their own deprescribing workflows.

Shannan Takhar, PharmD, BCACP
Clinical Pharmacist, Ambulatory Care
Department of Pharmacy Services
UC Davis Health
sktakhar@ucdavis.edu

Noelle Nelson, PharmD, MSPH
Clinical Pharmacist, Ambulatory Care
Department of Pharmacy Services
UC Davis Health
nnelson@ucdavis.edu

References

1. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. Am Fam Physician. 2019;100(1):32-38. Free full text
2. Maher Jr. RL, Hanlon JT, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1). doi: 10.1517/14740338.2013.827660 Free full text
3. Leelakanok N, Holcombe AL, Lund BC, et al. Association between polypharmacy and death: a systematic review and meta-analysis. JAPhA. 2017; 57(6):729-738. doi: 10.1016/j.japh.2017.06.002 Available at
4. Kim J, Parish AL. Polypharmacy and medication management in older adults. Nurs Clin North Am. 2017;52(3):457-468. doi:10.1016/j.cnur.2017.04.007 Available at
5. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6 Free full text
6. Page AT, Clifford RM, Potter K, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(3):583-623. doi: 10.1111/bcp.12975 Free full text
7. Elbeddini A, Zhang CXY. The pharmacist’s role in successful deprescribing through hospital medication reconciliation. Can Pharm J (Ott). 2019;152(3):177-179. doi: 10.1177/1715163519836136 Free full text
8. Whitman A, DeGregory K, Morris A, et al. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Center. 2018;26(12):4105-4113. doi: 10.1007/s00520-018-4281-3 Free full text
9. Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been and where it may be going. Drugs Aging. 2013;30(11). doi: 10.1007/s40266-013-0118-4 Free full text
10. Farrell B, Mangin D. Deprescribing is an essential part of good prescribing. Am Fam Physician. 2019;99(1):7-9. Free full text
11. Reeve E. Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice. J Pharm Prac Res. 2020;50:98-107. doi: 10.1002/jppr.1626 Available at
12. Scott IA, Pillans PI, Barras M, et al. Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. Ther Adv Drug Saf. 2018;9(9):559-573. doi: 10.1177/2042098618784809 Free full text
13. Resources for Patients and Health Care Providers. Deprescribing.org. https://deprescribing.org/resources/. Accessed September 28, 2021.
14. Endsley S. Deprescribing unnecessary medications: a four-part process. Fam Pract Manag. 2018;25(3):28-32. Free full text
15. 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;35(11):3323-3332. doi:10.1007/s11606-020-06089-2 Free full text
16. Ibrahim K, Cox NJ, Stevenson JM, et al. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr. 2021;21(1):258. doi:10.1186/s12877-021-02208-8 Free full text
17. Thillainadesan J, Gnjidic D, Green S, et al. Impact of deprescribing interventions in older hospitalised patients on prescribing and clinical outcomes: a systematic review of randomised trials. Drugs Aging. 2018;35(4):303-319. doi:10.1007/s40266-018-0536-4 Available at
18. Pelton L, Knihtila M. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines — Implementation Guide. Boston, Massachusetts: Institute for Healthcare Improvement; 2018. ihi.org http://www.ihi.org/resources/Pages/Publications/Evidence-Based-Medication-Deprescribing-Innovation-Case-Study.aspx) Accessed October 7, 2021.