Deprescribing

This advice is sourced from NHS Scotland, Clinical Medicine Journal, Dr Clifford Lisk and Dr Ros Taylor 

Polypharmacy increases the risk of drug interactions, hospital admission and can worsen frailty, falls and delirium.

Medicines are prescribed for 3 reasons:

  • prevention of future harm 
  • control of illness
  • symptomatic relief

Consider the original reason for each medication - then review whether it still has any symptomatic benefit -or whether it may now be causing harm.

Preventative medications to consider stopping:

Class of medicine Examples Reasons to consider stoppping Cautions/notes
All   Any drug that the patient doesn't take or doesn't tolerate. Review indication
Anticoagulants and anti-platelets Aspirin, clopidogrel, warfarin, DOACs

Avoid anti-platelet agents for primary cardiovascular prevention.

Stop anticoagulation where the risk of bleeding outweighs the risk of clots (for example in the case of a GI tumour)

Stopping anticoagulation/assessing bleeding risk is often a difficult decision which is best made with colleagues.

Consider using HAS-BLED to assess risk.

Anticholinergics Oxybutinin, Buscopan, Chlorphenamine, Amitriptyline Side effects include falls, dry mouth, constipation and confusion. Note the overall anticholinergic burden and whether some drugs can be omitted safely.
Antihypertensives ACE Inhibitors and ARBs, Alpha blockers, Diuretics, Calcium channel blockers

Often blood pressure reduces with advancing illness, and hypotension causes fatigue and falls.

Stop ACEi/ARBs that are used solely for renal protection (e.g in diabetes).

Diuretics in heart failure often need to be continued.
Dementia medications Antipsychotics, Aricept, Memantine

Consider reducing doses of antipsychotics if level of distress is low.

Memantine and Aricept are no longer of benefit in advanced disease and may cause falls and insomnia.

All dementia medications should be tapered rather than stopped suddenly.
Osteoporosis treatments  Bisphosphonates and calcium supplements

Unlikely to be of any benefit in the short term.

Weekly alendronate can cause oesophageal ulceration. 

 
Proton pump inhibitors and H2 receptor antagonists Lansoprazole, Omeprazole, Famotidine Should not be required at full therapeutic dose without a current indication (e.g for symptoms or gastroprotection)  May be required if on steroids or NSAIDs.
Oral hypoglycaemics Metformin, sulphonylureas, gliptins, glitazones

Prevention of future diabetic complications is no longer relevant.

Aim for monotherapy if any therapy is needed.

Aim for blood sugars 5-17
Lipid lowering treatments Statins, ezetimibe, bile acid sequestrants, fibrates Need to be prescribed for a long duration to be of benefit.  
Supplements Iron, Folate, Multivitamins Rarely relevant towards the end of life and add to the tablet burden.  

Top tips:

  • Review inhaler technique - these are often not properly used in advancing illness and can be stopped
  • Useful phrase "Some of your medicines that used to help you may no longer be of benefit''
  • Focus on the benefits of stopping rather than the futility of continuing
  • Always ask about 'over the counter' and herbal medicines

Sources

NHS Scotland - Polypharmacy

Published 30th June 2023

Clinical Medical Journal - Deprescribing in palliative care

Published 30th June 2023

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