Deprescribing in Internal Medicine: A Comprehensive Approach to Rational Medication Management

Dr Neeraj Manikath , claude.ai

Abstract

Deprescribing—the systematic process of tapering or stopping medications that may no longer be beneficial or may be causing harm—has emerged as a critical clinical skill in modern internal medicine. With polypharmacy affecting up to 40% of older adults and contributing to adverse drug events, hospitalizations, and reduced quality of life, the ability to safely reduce medication burden is essential for internists. This review synthesizes current evidence on deprescribing strategies, provides practical frameworks for implementation, and highlights clinical pearls for postgraduate trainees navigating this complex therapeutic domain.

Introduction

The contemporary practice of internal medicine is paradoxically characterized by both therapeutic abundance and iatrogenic complexity. While modern pharmacotherapy has dramatically improved outcomes across numerous disease states, the accumulation of medications—termed "prescribing cascade"—often occurs without corresponding reassessment of necessity. Studies indicate that approximately 50% of older adults take one or more potentially inappropriate medications, and adverse drug events account for nearly 10% of hospital admissions in this population.

Deprescribing represents a fundamental shift from the traditional "more is better" paradigm toward individualized, goal-concordant care. Unlike simple medication discontinuation, deprescribing is a deliberate, evidence-based process that weighs benefits, harms, patient preferences, and realistic treatment goals.

The Rationale for Deprescribing

Polypharmacy Burden

Polypharmacy, typically defined as the concurrent use of five or more medications, increases exponentially with age and comorbidity. The Beers Criteria and STOPP/START criteria have identified numerous medications that carry disproportionate risks in older adults. However, the challenge extends beyond simply avoiding "inappropriate" medications to questioning whether "appropriate" medications remain necessary as patients' clinical contexts evolve.

Pearl: The number five for polypharmacy is arbitrary; focus instead on whether each medication has a clear, current indication and whether benefits outweigh harms for the individual patient.

Physiological Changes with Aging

Age-related pharmacokinetic and pharmacodynamic changes fundamentally alter drug disposition. Reduced renal clearance, decreased hepatic metabolism, altered body composition, and increased blood-brain barrier permeability all contribute to drug accumulation and enhanced sensitivity. A medication dose appropriate at 65 may be excessive at 85, even without formal renal impairment.

Changing Goals of Care

Perhaps most importantly, therapeutic goals evolve. Medications initiated for primary prevention in a healthy 60-year-old may become questionable in an 85-year-old with limited life expectancy and functional decline. The time-to-benefit for interventions like statins, bisphosphonates, and tight glycemic control often exceeds remaining life expectancy in frail older adults.

A Systematic Approach to Deprescribing

Step 1: Comprehensive Medication Review

Begin with a complete medication inventory, including prescription medications, over-the-counter drugs, supplements, and herbal preparations. Medication reconciliation errors occur in up to 50% of care transitions, making this foundational step critical.

Hack: Ask patients to bring all medications in a bag ("brown bag review") or photograph their medication bottles. Electronic health records often contain discontinued medications or lack complete information about patient-initiated changes.

Step 2: Identify Deprescribing Targets

Several validated tools can guide this process:

STOPP/START Criteria: Screening Tool of Older Persons' Prescriptions identifies potentially inappropriate medications
Beers Criteria: American Geriatrics Society's list of medications with unfavorable risk-benefit ratios in older adults
Medication Appropriateness Index: Assesses indication, effectiveness, dosage, directions, practicality, drug-drug interactions, drug-disease interactions, duplication, duration, and cost

Priority targets for deprescribing include:

Medications without clear indication: Often remnants of past acute conditions
Medications causing adverse effects: Including falls, cognitive impairment, or gastrointestinal symptoms
Medications with drug-drug or drug-disease interactions
Medications unlikely to provide benefit given prognosis: Particularly preventive therapies
Medications used to treat adverse effects of other medications: Breaking the prescribing cascade

Oyster: Don't overlook vitamin D and calcium supplementation. While widely prescribed, evidence for fracture prevention is modest outside specific populations, and hypercalcemia can cause significant morbidity.

Step 3: Assess Risks and Benefits of Discontinuation

This requires understanding:

Time-to-benefit of the medication
Patient's life expectancy and quality of life priorities
Potential withdrawal syndromes or rebound phenomena
Previous responses to the medication

The concept of "life expectancy tables" is useful but imperfect. A 10-year cardiovascular risk calculator becomes less relevant when discussing an 82-year-old with heart failure and dementia. Incorporate functional status, frailty indices, and patient-centered outcomes.

Step 4: Prioritize and Create a Tapering Plan

Rarely should multiple medications be stopped simultaneously. Prioritization should consider:

Medications with highest harm potential
Those causing current symptoms
Patient and family preferences
Medications easiest to discontinue (least withdrawal risk)

Pearl: Start with medications the patient most wants to stop. Success builds confidence and engagement in the process.

Step 5: Implement Deprescribing with Monitoring

Specific tapering protocols vary by medication class:

Proton Pump Inhibitors: Often the lowest-hanging fruit. After 8+ weeks for appropriate indications, attempt cessation or transition to on-demand therapy. Expect rebound acid hypersecretion for 2-4 weeks; H2-receptor antagonists or antacids can bridge this period.

Benzodiazepines: Gradual taper over 4-12 weeks, reducing by 25% every 2 weeks. Shorter-acting agents should be converted to longer-acting equivalents (e.g., lorazepam to diazepam) before tapering. Monitor for withdrawal symptoms including anxiety, insomnia, and seizures.

Antihypertensives: In those >80 years with systolic BP <130 mmHg or orthostatic hypotension, consider reducing. Discontinue one agent at a time with BP monitoring every 1-2 weeks. Patients often tolerate removal of one agent without significant BP increase.

Statins: The number needed to treat for primary prevention increases dramatically after age 75. For those with limited life expectancy (<1-2 years), frailty, or polypharmacy burden, discontinuation is reasonable. Stop abruptly (no taper needed) with clinical monitoring.

Sulfonylureas: High hypoglycemia risk with minimal cardiovascular benefit. Consider replacement with safer agents or discontinuation if HbA1c <7% on multiple agents. If stopping, monitor glucose more frequently initially.

Anticholinergics: Including first-generation antihistamines, bladder antimuscarinics, and tricyclic antidepressants. Cognitive burden accumulates with anticholinergic load. Taper slowly to avoid cholinergic rebound.

Hack: Use the Anticholinergic Cognitive Burden Scale to quantify cumulative anticholinergic exposure. Scores ≥3 are associated with increased adverse outcomes.

Disease-Specific Considerations

Diabetes Management in Older Adults

The ACCORD trial demonstrated that intensive glycemic control (HbA1c <6.0%) increased mortality in high-risk patients. Current guidelines recommend individualized targets: HbA1c 7.0-7.5% for healthy older adults, 7.5-8.0% for those with comorbidities, and 8.0-9.0% for those with limited life expectancy or frailty.

Pearl: Insulin is frequently overdosed in nursing homes. If recurrent hypoglycemia occurs or HbA1c drops below target, proactively reduce doses by 20-30% rather than waiting for severe hypoglycemia.

Cardiovascular Medications

Aspirin for primary prevention in those >70 years shows no net benefit and increased bleeding risk per ASPREE trial. Secondary prevention remains important, but in patients with terminal illness or high bleeding risk, reassessment is warranted.

Beta-blockers post-myocardial infarction provide mortality benefit primarily in the first year; after 3 years in stable patients, continuation may be unnecessary unless another indication exists.

Osteoporosis Treatment

Bisphosphonates reduce fracture risk with a time-to-benefit of approximately 2 years. After 3-5 years of treatment and improvement in bone density, drug holidays are appropriate for many patients. Those with life expectancy <2 years or immobility (preventing falls from height) derive minimal benefit.

Overcoming Barriers to Deprescribing

Patient-Related Barriers

Many patients express reluctance to stop medications, particularly those prescribed by specialists or taken for many years. Effective communication strategies include:

Exploring patient concerns and acknowledging uncertainty
Framing deprescribing as active treatment optimization, not abandonment
Offering trial discontinuation with clear monitoring plans
Emphasizing patient autonomy in decision-making

Hack: Use the phrase "therapeutic trial" when discussing deprescribing. This reframes discontinuation as a time-limited experiment rather than permanent change, reducing anxiety.

System-Related Barriers

Electronic health record systems often lack decision support for deprescribing. Creating institutional protocols, order sets for medication tapers, and pharmacist-led medication review services can facilitate systematic implementation.

Prescriber-Related Barriers

Therapeutic inertia and concern about criticism from other providers impede deprescribing. Documentation should clearly state rationale, particularly when stopping medications initiated by specialists. Phrase documentation as "medication carefully reevaluated in context of patient's current goals and clinical status" rather than suggesting the initial prescription was inappropriate.

Special Populations

Palliative and End-of-Life Care

Patients with limited life expectancy (<6 months) should have aggressive deprescribing. Statins, bisphosphonates, antidementia drugs, and many preventive medications can be discontinued. Focus on symptom management and quality of life.

Oyster: Don't stop all medications reflexively. Anticonvulsants, antidepressants, and some cardiac medications may provide important symptomatic benefit even at end of life.

Cognitive Impairment and Dementia

Medication management becomes progressively challenging with cognitive decline. Simplifying regimens improves adherence and reduces errors. Cholinesterase inhibitors and memantine show modest benefit but may be reasonable to discontinue in advanced dementia (MMSE <10) or when adverse effects occur.

Post-Hospitalization

The peri-discharge period is high-risk for both prescribing cascades and inappropriate discontinuations. Medication reconciliation should explicitly address which new medications are temporary (e.g., antibiotics, short-term acid suppression) versus ongoing.

Outcomes and Evidence

Randomized controlled trials of deprescribing interventions have demonstrated:

Reduction in potentially inappropriate medications without adverse effects on quality of life or healthcare utilization
Improved cognitive function with anticholinergic deprescribing
Reduced falls with psychotropic medication reduction
High patient acceptability when deprescribing is conducted systematically

The CEASE trial showed successful discontinuation of statins in life-limited patients improved quality of life without increasing cardiovascular events. The TAPER trial demonstrated successful benzodiazepine discontinuation in 27% vs 5% with educational intervention.

Clinical Pearls and Practical Tips

Start conversations early: Frame deprescribing as routine medication optimization, not crisis intervention
One medication, one prescriber: Avoid simultaneous changes by multiple providers; coordinate through primary care
Document meticulously: Include rationale, monitoring plan, and patient agreement in medical record
Schedule follow-up: Most deprescribing requires monitoring; book follow-up before discontinuing
Expect some relapses: Some medications will need reinitiation; this doesn't represent failure
Consider financial burden: Medication costs may prevent adherence; deprescribing can improve adherence to essential medications
Leverage transitions: Hospital discharge, new diagnoses, and functional decline are natural opportunities to reassess medication appropriateness

Conclusion

Deprescribing represents a core competency for 21st-century internists. As our population ages and polypharmacy increases, the ability to thoughtfully reduce medication burden while maintaining quality of life becomes increasingly critical. Success requires systematic assessment, patient-centered communication, knowledge of medication-specific withdrawal risks, and longitudinal monitoring.

For postgraduate trainees, developing comfort with deprescribing early in training establishes patterns of practice that will serve patients throughout their careers. Each medication review is an opportunity to question whether we are serving our patients' best interests or simply maintaining therapeutic inertia.

The art of medicine increasingly lies not in knowing what to add, but in understanding what to take away.

References

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American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
O'Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.
Reeve E, et al. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738-747.
ACCORD Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559.
McNeil JJ, et al. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med. 2018;379(16):1519-1528.
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med. 2010;170(18):1648-1654.
Kutner JS, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691-700.
Tannenbaum C, et al. A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs. Drugs Aging. 2012;29(8):639-658.
Scott IA, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.

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