Deprescribing⬇️ Flashcards
(13 cards)
What is Deprescribing?
The planned, supervised process of reducing or stopping medications that may no longer be beneficial or may be causing harm.
Aimed at reducing problematic polypharmacy and improving patient outcomes.
Polypharmacy: Use of ≥5 medications; Hyperpolypharmacy: ≥10 medications.
🎯 Key Aims
Discontinue unnecessary medications
Minimize adverse drug events
Improve functional outcomes, especially in the elderly
Common Drivers of Polypharmacy
Multiple prescribers; poor communication across care settings
Patient/caregiver expectations or demands (e.g. from online research)
Prescribing cascade: healthcare provider misinterprets adverse drug event as a new condition and provides second drug to address side effects. Treating side effects of drugs with more drugs.
Therapeutic advancements & new drugs
Increasing age
Multiple long term conditions
Increased accessibility to medicines
NHS guidance & targets
Challenges
Fear of litigation
Lack of evidence for stopping treatments
Non-adherence (‘therapeutic failures’) , poor communication, and transfer of info
Poor medication review
Non-pharmacological options not readily available accessed
Treating condition vs person
Medication review: NO TEARS
Need/Indication – Is the drug still needed?
Open Questions – Ask patients about use & impact, lifestyle
Tests & monitoring – Is the drug effective or monitored appropriately?
Evidence & Guidelines – Does evidence support continuation?
Adverse Events – Any harm caused?
Risk reduction or prevention – Is the benefit still worth the risk?
Simplification & Switches – Can the regimen be simplified?
Deprescribing Tools
Anticholinergic Burden (ACB) Calculator – Quantifies cognitive risk
Opioid Equivalence Calculators – Convert to morphine equivalent dose
Local tapering templates for opioids/antidepressants
STOMP resources (Stopping Overuse of Medicines in People with Learning Disabilities)
Anticholinergic Burden
Used in: Parkinson’s, incontinence, COPD, depression, allergies
Risks: Cognitive decline (dementia risk) , falls, constipation, dry mouth, urinary retention
Anticholinergic Burden (ACB) Calculator – Quantifies cognitive risk
Scoring:
0: No burden (if cannot find medication listed in calculator)
1–3: Low–high burden
(1= possible anticholinergic burden) (2 or 3 = medication has definite anticholinergic burden)
Also offers alternatives with lower anticholinergic burden, considering patient suitability
E.g., Oxybutynin (score 3) → consider switch to Mirabegron (lower ACB)
Antidepressant Deprescribing
Consider benefits vs challenges
Use PHQ-9 to assess mood and readiness
Is it the right time?
Reduce dose 25–50% every 4 weeks, depending on stability
Taper gradually; avoid abrupt withdrawal, taper alongside non-pharmacological therapy eg guided self-help, counselling social prescribing)
Monitor for:
Withdrawal symptoms: nausea, low mood, anxiety. May be delayed with high doses fluoxetine, lunged half-life)
Relapse signs
Let them know beforehand. Are you in the right space to deal with that?
Use shared decision-making & provide safety netting (e.g., check-ins, support groups)
Opioid Deprescribing
Useful in acute & end-of-life pain, but harmful in chronic pain
Risks: Falls, fractures, endocrine dysfunction, dependence, hyperalgesia
Risks of harm increases substantially over 120 mg morphine equivalent/day = high risk, no increased benefit
Taper:
~10% every 1–2 weeks
Use patient-preferred formulations
Allow flexibility based on tolerance
Provide antiemetics if needed (avoid adding unnecessary meds)
Opioid calculators for morphine equivalents. Opioid reduction templates to see how much tapering down by.
STOMP Reviews: Learning disabilities & Autism
Many prescribed psychotropics for behavioural control rather than diagnosis (makes them drowsy as behaviour seen as challenging)
Consider non-drug alternatives first (e.g. communication tools, behavioural therapy)
Taper Risperidone (e.g., 2mg → 1mg → 0.5mg → stop)
Review Citalopram and Promethazine for sedation, fatigue
Involve:
Multidisciplinary team (MDT): carers, psychologists, community nurses
Use the patient/ carer/ parents / school input to gather info about behaviour before medication review
Use best interest decisions if no capacity (e.g., via DoLS)
Physical health monitoring:
Weight, HbA1c, Prolactin, and general wellness
Summary for Practice
Always involve the patient or their advocate
Make decisions based on:
Clinical evidence
Patient history
Side effects
Monitoring parameters
Deprescribing = an ongoing, patient-centred process
Possible plan for patient who would like to taper down her antidepressant (on 100mg sertraline once daily)
Use PHQ-9 to score mood and discuss how they feeling, is this the right time to taper
Tapering Schedule:
Weeks 1-2: Reduce to 75 mg once daily.
• Weeks 3-4: Reduce to 50 mg once daily.
• Weeks 5-6: Reduce to 25 mg once daily.
Week 7 onward: Discontinue
Challenges
Withdrawal Symptoms: Risk of withdrawal symptoms, including dizziness, irritability, and flu-like symptoms
Relapse Risk: Possibility of a return or exacerbation of depressive symptoms
Individual Variation: Tapering response varies among individuals
Benefits
Reduced Side Effects: Minimisation of medication-related side effects
Patient Autonomy: Empowers patients to actively participate in their mental health management
Cost and Convenience: Potential reduction in treatment costs and avoidance of long-term medication commitments
Counselling Points
• Expectation Management:
- Counselling: Discuss potential withdrawal symptoms and the gradual nature of the tapering process
Education: Emphasize that tapering should be a collaborative decision based on the individuals response to treatment
• Monitoring and Communication:
- Regular Check-ins: Schedule regular follow-up appointments during the tapering process
- Open Communication: Encourage to report any changes in mood, energy, or the emergence of withdrawal symptoms promptly
• Relapse Prevention Strategies:
Counselling: Discuss strategies to manage stress, maintain a healthy lifestyle, and recognize early signs of relapse
- Safety Plan: Collaborate on a safety plan in case of a sudden worsening of symptoms (friends/family support/ well-being groups)
Monitoring and follow-up
Weekly Monitoring (Weeks 1-4): Assess for withdrawal symptoms, mood changes, and overall well-being
Bi-Weekly Monitoring (Weeks 5-6): Continue to evaluate withdrawal symptoms and any return of depressive symptoms
Monthly Monitoring (Week 7 onward): Assess for long-term stability, monitor for any delayed emergence of symptoms, and provide ongoing support
Possible plan for 65-year-old male, has been on long-term opioid therapy with morphine (90 mg modified-release twice daily) for chronic back pain following a lumbar surgery three years ago. Your practice have identified him as someone who
takes >120mg morphine/day. You are asked to open a discussion about tapering this dose where he tells you the pain is worst in the morning and he can’t do without his medication in the morning.
When’s the pain at first?
Regime: reduce the night dose first
Reduction rate: 10% (20mg)
Is this the right time to taper, new consultation - need to discuss benefits and challenges ahead, which dose to reduce first of the right time?
Benefits
• Reduced Side Effects: Minimisation of opioid-related side effects, such as constipation and sedation, plus falls, fractures etc.
• Improved Functionality: Potential improvement in daily functioning without opioid-related impairment
• Reduced Tolerance: Mitigating the risk of opioid tolerance and dependence
Challenges
• Withdrawal Symptoms: Risk of withdrawal symptoms, including pain exacerbation, nausea, and insomnia
• Pain Management: Ensuring effective alternative pain management strategies are in place
• Psychological Impact: Addressing psychological dependence and fear of increased pain
Expectation Management
• Counselling: Discuss potential withdrawal symptoms and the gradual nature of the tapering process
• Education: Explain that tapering should be a collaborative decision based on the balance between pain control and minimizing opioid-related risks
Pain Management Alternatives
• Counselling: Introduce and discuss alternative pain management strategies, such as physical therapy, non-opioid analgesics, and non-pharmacological interventions
• Collaboration: Work together to find a personalised pain management plan
Psychological Support:
• Counselling: Address concerns about increased pain and provide psychological support
• Behavioral Strategies: Introduce relaxation techniques, mindfulness, and cognitive-behavioral strategies to manage pain perception
Calculators:
total daily dose online calculator
Possible tapering plan: online template
Consider formulations
Regular phone calls
Monitoring and follow-up (will be individual to person)
• Weekly Monitoring (Weeks 1-8): Assess for withdrawal symptoms, pain levels, and overall well-being
• Bi-Weekly Monitoring (Weeks 9-16): Continue to evaluate withdrawal symptoms, pain control, and overall functionality
• Monthly Monitoring (Week 17 onward): Assess for long-term pain control, monitor for any delayed emergence of symptoms, and provide ongoing support
STOMP review: Mark is a 28-year-old autistic male with a learning disability.
He is non-speaking but uses a communication board and gestures to express himself. He has recently moved into a new supported living residence after spending six years in his previous home. Mark has been prescribed psychotropic medications for challenging behavior and anxiety for the past seven years.
Current Medications
Risperidone 2 mg tablet: ONE to be taken daily (prescribed by psychistrist for aggressive outbursts such as hitting and pushing others)
Citalopram 20 mg tablet: ONE to be taken daily (originally prescribed for “low mood and anxiety”)
Promethazine 25 mg tablet: ONE to be taken at night (prescribed for sleep difficulties)
Presenting Issues
• Mark’s support worker and community nurse have raised concerns about his physical health and side effects from his medications. These include excessive weight gain, ongoing drowsiness, and reduced participation in daily activities.
Mark’s support worker believes his aggressive outbursts may be related to frustration rather than a psychiatric condition.
They have observed that Mark becomes agitated when he struggles to communicate his needs, such as wanting to go for a walk or asking for a snack. Additionally, Mark often appears withdrawn and tired, which may be linked to the sedative effects of his medications.
• Mark’s meals are prepared by his support team and are described as balanced. He participates in short daily walks, but due to his fatigue, his physical activity has reduced significantly.
• Mark has a Deprivation of Liberty Safeguard (DoLS) in place, and all medication and care decisions are made in his best interest, involving his parents, with his father as his authorised ‘relevant person’s representative.’ Mark does not tolerate blood tests well and has refused them multiole times
‘Mark’s support worker believes his aggressive outbursts may be related to frustration rather than a psychiatric condition’ = don’t need risperidone
Mark often appears withdrawn and tired, which may be linked to the sedative effects of his medications = promethazine
Multidisciplinary Team Involved:
• Psychiatrist (Dr. Lorna Patel) - Oversees Mark’s psychiatric care and medication review.
• Psychologist (Dr. Rachel Evans) - Assesses behavioral triggers and provides therapy-based interventions.
• Pharmacist (Daniel Wong) - Evaluates medication effectiveness, interactions, and side effects.
• Support Worker (Amy Clarke) - Monitors Mark’s daily activities and supports non-medication strategies.
• Community Nurse (Jack Roberts) - Monitors
Mark’s physical health, including weight and cardiovascular risk factors.
Side Effects Observed:
• Risperidone:
- Weight gain of 12 kg over 12 months (BMI now
37)
- Increased drowsiness and lack of motivation
- Prolactin levels unknown (has not been tested in over three years) (scared of needles = can try do it in home setting, numbing cream, may need sedative before bloods)
• Citalopram:
- Persistent fatigue and low energy
- Reduced engagement in activities
• Promethazine:
- Difficulty waking up in the morning
- Excessive daytime drowsiness
- What are the concerns regarding Mark’s current medications?
• Mark is experiencing significant side effects, including weight gain, drowsiness, and reduced participation in activities
• His challenging behaviors may be related to unmet communication needs rather than a psychiatric disorder - What alternative strategies should be explored?
• A behavioral assessment to understand triggers for Mark’s aggression
• Implementing non-medication interventions such as communication tools (e.g. picture exchange communication system)
• Increasing structured activities to promote engagement
Tapering plan: (25-50% each week)
3. What medication adjustments might be considered?
Proposed Tapering Plan - likely to try one medicine at a time
• Citalopram (Antidepressant Tapering Plan)
- Reduce from 20 mg to 10 mg daily for 4 weeks
- Then 10 mg every other day for 2 weeks
- Then stop if no withdrawal symptoms arise (monitor for mood changes)
-Monitoring by: Psychiatrist, Pharmacist, Support Worker, and Psychologist.
• Promethazine (Sedating Antihistamine Tapering Plan)
- Reduce from 25 mg to 12.5 mg nightly for 2 weeks
- Then 12.5 mg every other night for 2 weeks
- Then stop if no rebound insomnia occurs
- Monitoring by: Psychiatrist, Pharmacist, Support Worker, and Community Nurse.
• Risperidone (Antipsychotic Tapering Plan - Requires Psychiatrist Oversight)
- Reduce from 2 mg to 1.5 mg daily for 4-6 weeks
- Then 1 mg daily for 4-6 weeks
- Then 0.5 mg daily for 4-6 weeks
- Then review for full discontinuation
- Monitoring by: Psychiatrist, Pharmacist, Support Worker, and Psychologist
Is he calm? Happy?
Ensure regular reviews take place every 2-4 weeks then at 3 months for each medicine that is tapered.
- How will the MDT support Mark’s well-being during medication changes?
• Psychiatrist will oversee the medication reduction and monitor for withdrawal or relapse
• Psychologist will provide behavioral interventions and support Mark’s transition
• Pharmacist will track side effects and ensure safe dose adjustments
• Support Worker will document daily responses and implement alternative communication strategies, will monitor if adjustments impact daily life
• Community Nurse will monitor physical health markers, including weight and metabolic effects - What physical health checks should be prioritised?
• Prolactin levels, blood glucose, and cholesterol due to risperidone’s metabolic effects
• Regular weight and BMI monitoring
• Consider alternative methods for blood testing if Mark struggles with traditional procedures
