GP Connect Clinical Feature by Amanda Quek (Pharmacist, PhD candidate), Prof Christopher Etherton-Beer (Geriatrician, Clinical pharmacologist) and A/Prof Amy Page (Consultant pharmacist, Biostatistician), A/Prof Kenneth Lee (GP practice pharmacist, Biostatistician), Dr Xisco Reus (GP); University of Western Australia Deprescribing Guidelines Steering Committee.
Deprescribing is an essential aspect of good prescribing practice. However, a barrier frequently reported is the lack of clear, evidence-based guidance. New deprescribing guidelines (available at deprescribing.com) are now available to support clinicians, including GPs, with practical recommendations for safely reducing or stopping medicines in older people (aged 65 years and over).1
These guidelines, endorsed by the RACGP and ANZSGM, are based on evidence specific to older people and include deprescribing recommendations for many common medicines. In addition to drug-specific guidance on when and how to deprescribe, the guidelines also outline overarching principles for addressing polypharmacy. As with any clinical guideline, it remains essential to apply clinical judgment and to consider individual values, preferences, and overall goals of care.
The guidelines have been designed to meet the needs of a broad audience. Concise summary documents are available for quick reference, alongside comprehensive technical materials for those seeking further detail. While particularly relevant to doctors, pharmacists, and nurse practitioners, the guidelines were informed by input from a wide range of health professionals, including those in disciplines such as optometry, dentistry and diabetes education.
Consumer input was an integral part of the guideline development process. A lay summary has been developed to assist individuals and their families in understanding the rationale and process of deprescribing. Ultimately, the guidelines aim to support shared decision-making between individuals and health professionals, ensuring that medicine management aligns with each individual’s health priorities and goals of care.
Example of a prescribing cascade
Rose, an 85-year-old woman, was hospitalised after a hip fracture sustained during a fall at home following an episode of urinary incontinence. She reported that her incontinence had worsened over the preceding weeks. She had recently started taking donepezil for Alzheimer’s disease. While in the hospital, oxybutynin was prescribed to manage her incontinence. This case illustrates a prescribing cascade, where a new medicine (oxybutynin) is started to treat a side effect of another drug (donepezil).
Over time, Rose developed xerostomia and difficulty swallowing, likely from oxybutynin. These symptoms caused a choking episode during meals. As a result, she was referred to a dietitian and started oral lubricants. This example shows how an inappropriate prescribing cascade can escalate. It can lead to additional adverse effects and reduce a person’s quality of life.
Deprescribing principles should be applied by reviewing the ongoing need for the medicines, carefully weighing potential harms and benefits, and engaging the individual in shared decision-making. When appropriate, tapering or discontinuing medicines can reduce medicine-related harm, simplify treatment regimens, and improve overall quality of care. Deprescribing should be an integral part of prescribing, not an afterthought, and regular medication reviews should be embedded in practices.
For more information, visit deprescribing.com
References:
1 Quek HW, Page A, Potter K, Etherton-Beer C. Deprescribing considerations for older people in general practice. Aust J Gen Pract. 2023 Apr;52(4):173-180. doi: 10.31128/AJGP-08-22-6547.