I’d venture a guess that many of my readers won’t have heard of the word deprescribing. As physicians, we’re generally trained to prescribe, not deprescribe. In fairness, we did have some discussions in residency on polypharmacy (too many meds) and its effect on patients. But that was about the extent of it.
Yesterday, I saw an 85-year-old in the office. It was only my second time seeing him, so I don’t know his history well. (It takes me a couple visits before I can put a patient story together in my head and have it stick.) I noted 9 medications on his med list. So I asked him:
Would you be willing to come off some of these meds?
His response?
Why certainly!
A family member who was with him said that he’s taking all of these meds, but they aren’t really sure what they’re all for!
Since we’re only 3 weeks into a new EMR system, I jotted some notes for myself so I could update his chart later in my office. This is what I jotted down:
His A1c was 6.4, which based on [age greater than 70 divided by 10] could acceptably be a lot higher. So, we could safely get rid of the glimepiride. In my clinical opinion, I’ve never found finasteride very effective—he agreed—so we’ll eliminate that. At his age, there’s no indication for 80 mg of atorvastatin, so we’ll cut that in half. We’ll check a lipid panel in the summer, and I’ll likely stop it entirely then along with one or two more.
His family member then reminded me of my interaction with her 8- to 10-year-old son 12 to 15 years previously. He had been diagnosed with a form of inflammatory bowel disease by a pediatric gastroenterologist and was placed on a prohibitively expensive biologic and was told he’d need to be on this for life. The specialist wanted to do more testing. I (didn’t remember that I) said to her:
“Well, what would happen if we simply stopped it?”
Her response:
That commonsense approach was exactly what I needed to hear as a much-younger mother to make me comfortable stopping it.
The result? They stopped the medicine, and he’s had absolutely no issues ever since! That was at least 12 years ago.
My immediate prior patient of the same morning admitted that he had “white coat hypertension.” He told me it stemmed from an interaction with the medical establishment some 20+ years previously. He was on at least 15 different medications at the time. He was nearly bedridden for about a 3-month period. He went to see a specialist who started looking through his pill bottles and one by one chucked them in the waste can, ending by saying:
What are they trying to do? Kill you?!
That physician must have been an expert in deprescribing! Yesterday, he was only on 3 meds, two of which are used only as needed.
How did this come to be a routine part of our clinical practice?
Dr. LuAnne and I were co-medical directors at a local retirement facility for about 5 years. We took this position seriously and became “certified medical directors” through the AMDA (American Medical Director’s Association). At the time, we were 2 of only about 3,000 in the country. (We’ve since let that certification lapse since we don’t do nursing home medicine anymore.) When new residents were admitted to the facility, their medicines in the MAR (Medication Administration Record) covered 4 to 5 pages on average. We said to each other:
What would happen if we attempted to pare this down to 1 or 2 pages?
And so we did. I soon realized that almost every resident had a diagnosis of GERD. I thought, there’s no way that every resident in this facility has reflux! So, I’d write an order to “Stop Protonix; monitor for any symptoms of reflux and notify physician if so.” I don’t recall ever being notified, and when I did my quarterly rounds, I’d ask the resident, and no one was having reflux!
It was standard hospital protocol at the time that everyone got put on a PPI (gastric protection in light of stressful hospital environment was the rationale), and most of these nursing home residents had at some point been in the hospital. (It turned out that the local hospital apparently had a contract with the makers of Protonix, because that was the single medicine everyone was put on.) At hospital discharge, they went home with their PPI and a diagnosis of GERD, and few physicians ever questioned that diagnosis, and many stayed on the medicine for years—despite the fact that their indication was 8 to 12 weeks max in the majority of patients.
And then one day I was sitting with the facility’s clinical pharmacist who was doing his monthly med review of the charts. He said:
You know there’s emerging evidence that these PPIs are leeching calcium out of bones.
…not a good thing for an elder in a nursing home!
We successfully pared most resident’s MAR list to one or two pages, and I don’t recall a single negative result of that. I’d like to think there was positive impact.
I’ll never forget the case of MS. MS had a significant cardiac history. She was a resident of the above nursing home. She was on about 6 cardiac meds, as I recall. In discussion with her and her family, we mutually agreed that it was time to bring hospice on board. The standard practice is to stop most medications during that process. I believe I stopped everything on MS except her Lasix.
At the end of one month, MS was still living. Two months came, then three. At six months, MS was still going strong. She lived for a full year after stopping all of those “life-sustaining” cardiac meds. I said to myself:
Either those meds were so effective they are still in her system, or they really didn’t do what we thought they did.
Now understand, I don’t deprescribe cavalierly. It’s done one patient at a time, and it’s based on each patient’s individual history. This is not a “one-size-fits-all” process, and it’s not meant as advice for my readers to just up and stop their meds! But I’ve learned several things about this process after two decades of medical practice:
Few (if any) patients are asking to be put on more meds.
Most patients appreciate the thoughtful process of deprescribing. My 85-year-old told me at the end of yesterday’s visit, “I really appreciate you looking through all of my meds and seeing what we can cut out.”
Most patients have improved outcomes and quality of life through this process.
I rarely if ever prescribe a medicine to take care of a side effect of another medicine. I rather address the first medicine causing the side effect.
The strong medical recommendation and indication for many medications is often directly correlated to the existing patent on the medication. Plavix (clopidogrel) is a great example. When I was in training, if you had a TIA or stroke, you got put on Plavix for life. Now, neurologists routinely discharge people from hospital after either with “ASA 81 mg + clopidogrel x 21 days, then ASA only thereafter.” I admit that I’ve not done a deep dive into why this recommendation has changed so dramatically, but I would suspect it’s connected to $$$.
And so, it keeps us all humble. Senator Rand Paul (an MD/ophthalmologist) did a great monologue recently during RFK Jr’s Senate hearings where he among other things used the previous recommendation for ASA (aspirin) for all being completely turned on its head—an example I’ve also used often to show that we must keep an “open mind” about our medical recommendations.
And so, “ask your doctor if deprescribing is right for you”!
I believe there are exciting days ahead of us.
Soli Deo Gloria!
Thought provoking article, with a lot of case-study to back it up!!! Thanks so much Doc!
Great, great article.