Unveiling the latest deprescribing research: a new themed collection

Deprescribing

A culture of prescribing to treat long-term conditions, coupled with age-associated changes in the processes of metabolising medicine, have led to an ‘overprescribing epidemic’ amongst older adults. The World Health Organization recognises overprescribing as a serious problem yet deprescribing of medicines with more risks than benefits is not routine practice.

While discontinuing medicines with more risks than benefits has long been a component of good prescribing practice, the term deprescribing was coined by Michael C. Woodward in 2003^[1] from which a burgeoning research field has emerged. It is widely recognised that deprescribing medicines are safe and none of the many large-scale trials have reported an increased risk of adverse drug withdrawal events.^[2] While less conclusive, trial evidence also now supports an association between deprescribing and a reduction in; adverse drug events, falls, and hospital admissions.

Despite the potential to improve outcomes for patients and evidence to support the absence of harm from deprescribing, patients continue to be prescribed medicines offering more risks than benefits. This Themes Collection of the International Journal of Pharmacy Practice invited submission of manuscripts contributing to the ambitious goal of achieving a sustained translation of deprescribing into routine clinical practice. The Special Issue makes a significant contribution to the deprescribing literature by quantifying and characterising the problem that deprescribing seeks to address and further evidencing the likely benefits of deprescribing. It also describes the barriers and enablers to deprescribing from the perspectives of healthcare professionals and patients and showcases the development and evaluation of novel deprescribing interventions to address them.

Quantifying and characterising the problem and evidencing the likely benefits

A prospective observational study across three fracture clinics in England reported that 73% of older adults with a limb fragility fracture were prescribed at least one medicine with a fall risk, predisposing them to further fractures.^[3] Despite an expert consensus study ranking proton pump inhibitors fifth in order of priority to be targeted for deprescribing,^[4] a retrospective analysis of prescribing data at a hospital in Thailand found that prescribing volumes had increased significantly between 2016 and 2018.^[5]

A systematic review of randomised controlled trials adds to the literature indicating that deprescribing interventions have a positive effect on patient outcomes including a reduction in medicines burden and improvements in health-related quality of life. The review also maps deprescribing intervention to the Consolidated Framework for Implementation Research to support selection of evidence-based components in future intervention development.

Barriers and enablers to deprescribing

Much research has focussed on quantifying the extent patients’ and personal consultees’ attitudes towards deprescribing.^[6] Research consistently shows that the concept of deprescribing is highly acceptable however clinical trials report up to half of the patients report not wanting to have a medicine stopped.^[7] This is reinforced by a study embedding a novel card sorting activity reported that the vast majority are resistant to deprescribing non-prescription medicines.^[8] A qualitative interview study with 38 older adults who had recently had a medicine deprescribed and their informal carers shed light on the disconnect between attitudes and action. It reports the importance of contextual factors on patient decision-making and proposes a model for patient-centred deprescribing.

The importance of applying theory to understand the barriers and enablers to deprescribing is increasingly recognised as important.^[9] A qualitative exploration of doctors, nurses and pharmacists across four hospices in Northern Ireland was underpinned by Theoretical Domains Framework.^[10] Lack of feedback on deprescribing outcomes, challenges holding deprescribing discussions with patients and families and the absence of deprescribing tools were all barriers. Access to information regarding what and how to deprescribe was an enabler. The COM-B model of behaviour was used as a lens through which to describe the barriers and enablers to deprescribing postoperative opioids. Provision of educating to prescribers about the risks of failing to deprescribe opioids when clinically appropriate and clinical practice guidelines were identified as necessary interventions however if implemented in isolation were unlikely to be effective. Addressing competing priorities such as pressure to discharge patients and presumptions that primary care healthcare professionals are aware of whether opioids should be ceased or continued after surgical discharge are also necessary.

Two community pharmacy-based studies in the United Arab Emirates and the UK similarly reported perceived patient resistance to be a key barrier. A systematic review of primary care literature underpinned by Normalisation Process Theory reported that healthcare professional’s negative perceptions about the potential adverse consequences was a barrier while provision of education and training was an enabler.^[11]

Deprescribing interventions

In response to calls from healthcare professionals for the availability of tools to support deprescribing decision-making, a systematic review identified and considered the rigour with which tools to support deprescribing for older adults with limited life expectancy were developed.^[12] It highlights that while a large number of deprescribing tools have been developed, very few have been validated for use in older adults with limited life expectancy. Deprescribing guidelines are an alternative to tools that are also designed to support decision-making. An innovative evaluation approach used whiteboard videos on YouTube to explain deprescribing guidelines and measure the extent to which knowledge mobilisation was successful.^[13]

Challenges holding deprescribing discussions with patients and families were highlighted as a barrier earlier in this editorial. An evaluation of a novel Medicines Conversation Guide to support deprescribing discussions found that the majority of General Practitioners interviews said they would use the intervention in practice because it supported them to empower patients to take ownership of deprescribing decisions.^[14]

An evaluation of integrating pharmacists into general practice in Australia saw 54% of patients have a medicine recommended for deprescribing, of which the vast majority were accepted. Opioids were the most common medicine deprescribed with effects sustained at 9 months. Interviews with pharmacists identified that enablers to deprescribing were recognition that pharmacists’ role includes deprescribing, being embedded in the general practice team and a supported approach to shared decision-making.

A randomised controlled trial testing the effectiveness of an integrated medicines management intervention demonstrated a change in healthcare professionals’ deprescribing behaviour evidenced by patients in the intervention arm being discharged on significantly fewer medicines that control patients.^[15] However, this difference was not replicated for potentially inappropriate medicines defined using the STOPP-2 criteria.^[16]

Moving forward

A newly launched Themed Collection on Deprescribing Themed Collections | International Journal of Pharmacy Practice | Oxford Academic (oup.com) illustrates the breadth and diversity of recent deprescribing research that is leading the way in understanding, developing and evaluating innovative strategies to make deprescribing routine practice. As we draw ever nearer to achieving this goal, the focus of research will continue to evolve as the challenges change. We will continue to add emerging deprescribing evidence to this Themed Collection so that it maintains its currency as the home of high-quality research relevant to the field.