Deprescribing: Information for clinicians

Class of medicine

Examples

Reasons to consider stoppping

Cautions/notes

All

Any drug that the patient doesn't take, can't swallow or doesn't tolerate.

Review indication

Anti-anginals

GTN, Isosorbide mononitrate

If no angina symptoms (these often reduce in advanced illness as people move less) 

Ensure patient still has access to GTN spray for acute symptoms.
Monitor for recurrence of angina.

Anticoagulants and anti-platelets

Aspirin, Clopidogrel, Warfarin, DOACs (eg Apixaban),

LMW heparin injections

Avoid anti-platelet agents if only for primary cardiovascular prevention.

Stop anticoagulation where risk of bleeding outweighs the risk of clots (e.g 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.

Anti-arrhythmic drugs including beta-blockers

Bisoprolol, Carvedilol

Can cause hypotension

Contribute to fatigue

If symptomatic tachycardias are present, or if a betablocker is also helping angina, it may be advisable to continue treatment. 

Antihypertensives

ACE Inhibitors and ARBs,

Alpha blockers, Diuretics, Calcium channel blockers eg Amlodipine

Blood pressure often 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 usually need to be continued.

Dementia medications

Antipsychotics, Aricept, Memantine

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

Aricept and memantine may cause falls and insomnia and should be reviewed in advanced disease for benefit vs harm.

Some dementia medications should be tapered rather than stopped suddenly.

Cardiac glycosides

Digoxin

Impaired renal function can cause Digoxin toxicity (nausea, visual disturbance, arrhthmias)

Can contribute to hypotension and fatigue

Provides symptom relief in heart failure.

Narrow therapeutic window; monitor renal function and electrolytes.

Watch for signs of toxicity

Osteoporosis treatments 

Bisphosphonates and Calcium supplements

Unlikely to be of benefit in the short term.

Weekly Alendronate can cause painful oesophageal ulceration

Proton pump inhibitors and H2 receptor blockers

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 6-15

Lipid lowering treatments

Statins, Ezetimibe, Bile acid sequestrants, Fibrates

Unlikely to be of benefit in the short term

Supplements

Iron, Folate, Multivitamins

Rarely relevant towards the end of life and add to the tablet burden.