Deprescribing is the systematic process of discontinuing medications used for the management of chronic illness as patients’ survival time decreases.

Potentially inappropriate medications at the end of life
There are evidence-based guidelines for the initiation of pharmacologic therapy, however few addresses discontinuation. This unbalance, along with other barriers, often leaves patients on an abundance of medications near the end-of-life. Research has suggested the use of preventive medications such as aspirin, anti-hypertensives, and statins ranges between 29-51% in patients with a limited life expectancy, even though the timeframe of likely benefit for these medications may be far longer than a patient’s expected survival.
Frequently symptom-based medications are added to the end-of-life care plan, and many patients also may be taking vitamins, herbals or other supplements. Consequently, pill-burden can lead to unnecessary adverse drug reactions and increased cost of treatments.

Deprescribing involves a systematic clinical approach to identifying and discontinuing drugs for which the harms outweigh benefits within the context of an individual patient’s care goals, level of functioning, and life expectancy. It should be considered in any patient with a life-limiting illness. Medications considered for deprescribing include aspirin, anticoagulants, anti-hypertensives, statins, and anti-diabetic medications. Over-the-counter medications, vitamins, herbals, and supplements should be reviewed to determine if they have ongoing role in their care.

Some barriers to deprescribing
• Patient’s psychological attachment to a chronic medication, especially when a patient may associate the preventive medication as necessary for their long-term health. Effective discussions about deprescribing should be part of a conversation clarifying estimated prognosis and goals of care.
• Clinician litigation fears regarding a bad clinical outcome status post deprescribing.
• Risk of adverse withdrawal events.

Deprescribing framework
The Holmes’ model is a useful framework for deprescribing. It considers four factors: (A) two patient-specific factors - goals of care and prognosis, and (B) two medication specific factors - treatment target and time-until-benefit. Treatment target refers to the medication’s prevention strategy goal.

Deprescribing process
1. Ask a pharmacist to perform a complete medication reconciliation with focus on the respective indications.
2. Consider the patient’s goals, prognosis, and risk of drug-induced harm. Additional risk factors include the patient’s age and total number of medications.
3. Assess each medication’s risk/benefit ratio, with attention to treatment target and time-until-benefit.
4. Discontinue medication(s) based on priority.
5. Monitor for potential adverse drug withdrawal events.

See reference for more information.

Adapted from Pruskowsky J. Deprescribing. Palliative Care Network of Wisconsin. Fast facts and concepts # 321. Internet. Accessed on July 14, 2024.