Deprescribing in Chronic Illness: What Every Physician Should Know

Dr Neeraj Manikath , claude.ai

Abstract

Polypharmacy in patients with chronic illnesses represents a growing challenge in modern medicine, with adverse drug events contributing significantly to morbidity, mortality, and healthcare costs. Deprescribing—the systematic process of tapering or stopping medications that may no longer be beneficial or may be causing harm—has emerged as an essential competency for internists. This review examines the evidence-based approach to deprescribing, identifies high-risk medications, and provides practical frameworks for implementation in clinical practice.

Introduction

The paradigm of "more is better" in chronic disease management has been progressively challenged over the past two decades. Approximately 40% of older adults take five or more medications daily, with 20% taking ten or more. While guideline-directed therapy often necessitates multiple medications, the cumulative burden frequently exceeds benefit, particularly as patients age, develop functional decline, or experience changes in treatment goals.

The term "deprescribing" was formally introduced in 2003, defined as the systematic process of identifying and discontinuing drugs when existing or potential harms outweigh existing or potential benefits within the context of an individual patient's care goals, current level of functioning, life expectancy, values, and preferences. This process requires clinical acumen, shared decision-making, and systematic monitoring—skills that should be fundamental to internal medicine practice.

The Case for Deprescribing

Epidemiology of Polypharmacy-Related Harm

Adverse drug events account for nearly 100,000 emergency department visits annually among older adults in the United States, with anticoagulants, diabetes medications, and opioids representing the highest-risk categories. Each additional medication increases the risk of drug-drug interactions exponentially rather than linearly. Beyond acute toxicity, polypharmacy contributes to falls, cognitive impairment, functional decline, and decreased quality of life.

Pearl: The number of medications predicts adverse outcomes more reliably than individual high-risk medications in many populations.

The Prescribing Cascade

A particularly insidious consequence of polypharmacy is the prescribing cascade, where adverse effects of one medication are misinterpreted as new medical conditions, prompting prescription of additional medications. Classic examples include treatment of metoclopramide-induced parkinsonism with levodopa, or management of NSAID-induced hypertension with additional antihypertensives.

Oyster: Always ask "Could this be a drug side effect?" before initiating new therapy for new symptoms.

Identifying Candidates for Deprescribing

High-Risk Medications

Certain medication classes warrant particular scrutiny:

Proton Pump Inhibitors (PPIs): Over 50% of PPI use lacks appropriate indication. Long-term use associates with increased risks of Clostridium difficile infection, bone fractures, hypomagnesemia, and possibly chronic kidney disease. Studies demonstrate successful discontinuation in 60-80% of patients without indication, with minimal symptom recurrence when tapered appropriately.

Benzodiazepines and Z-drugs: These agents increase fall risk, cognitive impairment, and motor vehicle accidents in older adults. The Beers Criteria explicitly recommend avoidance in adults over 65. Gradual taper protocols demonstrate success rates exceeding 60% with appropriate support.

Antihyperglycemics in older adults: Intensive glycemic control (HbA1c <7%) provides minimal benefit and increases hypoglycemia risk in patients with limited life expectancy or advanced complications. Liberalizing targets to 7.5-8.5% often permits medication reduction without adverse outcomes.

Antihypertensives: The OPTIMIZE trial demonstrated that withdrawal of antihypertensives was feasible in patients with controlled blood pressure on multiple agents, with 30% remaining normotensive after discontinuation. Deprescribing is particularly appropriate in patients with orthostatic hypotension, frequent falls, or advancing frailty.

Statins for primary prevention: The time-to-benefit for cardiovascular risk reduction with statins is approximately 2-3 years. In patients with limited life expectancy or significant comorbidities, discontinuation may be appropriate. The SITE trial showed no increase in cardiovascular events at one year following statin discontinuation in palliative care patients.

Hack: Use the "START, STOP, and WAIT" framework—some medications need starting, others stopping, and some require observation before deciding.

Tools and Criteria

Several validated instruments assist in identifying potentially inappropriate medications:

The Beers Criteria, updated biennially by the American Geriatrics Society, catalogs medications to avoid in older adults. The STOPP/START criteria (Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment) provide both explicit criteria for potentially inappropriate medications and indicators for prescribing omissions. The Medication Appropriateness Index assesses ten dimensions of prescribing appropriateness.

Pearl: No tool replaces clinical judgment. These criteria provide starting points, not absolute rules.

The Systematic Approach to Deprescribing

Step 1: Comprehensive Medication Review

Document all medications including prescription drugs, over-the-counter medications, supplements, and herbal products. Verify actual medication-taking behavior, as non-adherence often masquerades as therapeutic failure. Identify prescribers and indications for each medication.

Oyster: Medication reconciliation errors occur in up to 50% of transitions of care. Never assume the medication list is accurate without verification.

Step 2: Assess Goals of Care

Engage patients in shared decision-making regarding treatment priorities. Does the patient prioritize longevity, symptom control, functional independence, or quality of life? These conversations transform deprescribing from a prescriptive process into collaborative care planning.

Step 3: Risk-Benefit Analysis

For each medication, consider:

• What is the indication, and is it still valid?
• What is the time-to-benefit, and does this align with life expectancy and goals?
• What are the potential harms, and do they outweigh benefits?
• Are there alternative non-pharmacologic interventions?
• What monitoring has been performed, and what do results suggest?

Step 4: Prioritization

Begin with medications causing current symptoms, those with highest risk, and those lacking clear indication. Consider patient preferences and feasibility. Avoid attempting to deprescribe multiple medication classes simultaneously unless circumstances require urgent intervention.

Step 5: Implementation and Monitoring

Develop a specific tapering plan when indicated. Abrupt discontinuation of benzodiazepines, beta-blockers, baclofen, gabapentin, and corticosteroids may precipitate withdrawal syndromes or rebound phenomena. Establish monitoring parameters and follow-up intervals. Document the rationale clearly to prevent inadvertent reinitiation.

Hack: Create a "deprescribing prescription" with specific instructions for tapering, monitoring, and contingency planning.

Condition-Specific Considerations

Deprescribing in Advanced Dementia

Patients with advanced dementia derive questionable benefit from cardiovascular prevention medications. The D-PREPARE trial demonstrated feasibility of deprescribing in this population. Prioritize medications for symptom control while considering discontinuation of statins, antihypertensives (if not needed for symptom management), and vitamin supplements.

Deprescribing in Heart Failure

While guideline-directed medical therapy remains foundational, specific scenarios warrant reconsideration. In patients with persistent hypotension limiting uptitration of beneficial medications, consider deprescribing medications with less robust mortality benefit. Non-dihydropyridine calcium channel blockers rarely benefit heart failure patients and should be discontinued.

Deprescribing in Chronic Kidney Disease

As renal function declines, medication accumulation and adverse effects increase. Systematic review of dosing, elimination pathways, and necessity becomes paramount. Metformin, NSAIDs, and certain antibiotics require particular attention. Some patients with stage 5 CKD not pursuing dialysis may benefit from deprescribing nephrotoxins and medications aimed at slowing progression.

Deprescribing in Multimorbidity

Patients with multiple chronic conditions face the greatest polypharmacy burden. Evidence for treatment in multimorbidity is limited, as clinical trials typically exclude such patients. Prioritize medications with the strongest evidence, highest symptom benefit, and best tolerability.

Pearl: "Mild disease deserves mild treatment"—avoid aggressive pharmacotherapy for asymptomatic or mildly symptomatic conditions in multimorbid patients.

Barriers to Deprescribing and Strategies to Overcome Them

Physician Barriers

Physicians cite lack of time, concern about discontinuing medications initiated by specialists, fear of adverse outcomes, and insufficient training as barriers. Systematic deprescribing protocols, team-based approaches involving pharmacists, and protected time for comprehensive medication reviews address these concerns.

Patient Barriers

Patients may resist deprescribing due to attachment to medications, fear of disease progression, or previous negative experiences with medication changes. Patient education materials, emphasis on personalized care, and gradual approach with close monitoring improve acceptance. Framing deprescribing as "prescribing something better" (fewer pills, fewer side effects) enhances patient buy-in.

Hack: Use motivational interviewing techniques. Ask "What concerns you most about your current medications?" before proposing changes.

System Barriers

Healthcare systems often incentivize prescribing over deprescribing, with quality metrics focused on medication initiation rather than appropriateness. Performance-based measures that assess polypharmacy and potentially inappropriate medications would better align incentives with optimal care.

Practical Pearls and Clinical Hacks

1. The "Brown Bag Review": Ask patients to bring all medications to appointments. This simple intervention reveals medication hoarding, expired prescriptions, and non-adherence patterns.

2. The "Medication Timeline": Create a visual timeline showing when each medication was started and what happened afterward. This often reveals prescribing cascades and helps identify which medications might be unnecessary.

3. The "Pause and Monitor" Approach: For uncertain scenarios, temporarily pause a medication (with patient agreement) and closely monitor rather than committing to permanent discontinuation immediately.

4. The "One-Thing Strategy": If overwhelmed by polypharmacy, commit to addressing just one medication per visit. Consistency over time yields substantial impact.

5. The "Symptom Diary": Have patients track symptoms during deprescribing. This provides objective data about whether discontinuation causes problems and empowers patients as active participants.

Oyster: The medication most difficult to deprescribe is often the one causing the most problems. Persistence and patient partnership overcome resistance.

Future Directions

Emerging research explores decision support tools, predictive analytics to identify deprescribing candidates, and standardized outcome measures for deprescribing trials. Pharmacogenomics may eventually guide personalized deprescribing strategies. Integration of deprescribing into medical education and training programs will create a generation of physicians skilled in this essential competency.

Conclusion

Deprescribing represents a fundamental clinical skill for modern internists, requiring the same rigor and evidence-based approach as prescribing. As the population ages and chronic disease burden increases, the ability to thoughtfully reduce medication burden while maintaining quality of life becomes increasingly critical. Every physician should view deprescribing not as therapeutic nihilism but as personalized, patient-centered optimization of pharmacotherapy.

The art of medicine has always balanced intervention with restraint. In our current era of polypharmacy, deprescribing may be among the most therapeutic interventions we offer our patients.

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Key References

1. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.

2. American Geriatrics Society Beers Criteria Update Expert Panel. 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.

3. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268.

4. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354-364.

5. Kutner JS, Blatchford PJ, Taylor DH Jr, 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.