Management of polypharmacy: can we safely discontinue medications?

Editor, – The authors of the article on deprescribing (Aust Prescr 2011;34:182-5) remind us about the critical role all clinicians play in generating, and potentially mitigating, polypharmacy. There is a paucity of high quality evidence to guide when to discontinue medications, especially where the event to be avoided may not be experienced for years or decades.

Initiating any medication requires a framework to evaluate its continuing use and includes:

• explicitly categorising the level of prevention (primary, secondary or tertiary) that the new medication is addressing
• agreed, measurable and clinically relevant endpoints
• the time by which clinical benefits are likely to be experienced
• the time frame for expected toxicities
• the time period in which it is likely that a condition will manifest after a medication is stopped
• a plan to individually balance the net clinical benefit (observed clinical benefits vs harms).^1,2

As a patient’s overall clinical condition, prognosis and range of comorbid illnesses shift over time, their individual benefit:harm ratio will need to be updated continually for each long-term medication. Individually, the number needed to treat and the number needed to harm are not static nor linear over time, and the ratio between them will shift from the time each medication is introduced.³

With so much effort expended by industry establishing the short-term efficacy of medications that will be used in the long term, it is time for an expansion of comparative effectiveness research defining when long-term medications can be ceased safely and in which sub-populations this should occur.^4,5 To minimise iatrogenic morbidity and premature mortality, publicly funded studies to develop credible evidence are needed urgently to inform timely and confident discontinuation of appropriate medications.

David C Currow
Palliative and Supportive Services
Flinders University, Adelaide

Jean S Kutner
Division of General Internal Medicine
University of Colorado, USA

Amy P Abernethy
Duke Cancer Institute
Duke University Medical Center
North Carolina, USA

Danijela Gnjidic, David Le Couteur, Emily Banks and Andrew McLachlan, authors of the article, comment:

We thank David Currow and his colleagues for their comments. We agree strongly with them and would like to see randomised controlled trials of long-term use of medicines and outcomes of judicious cessation of medicines in older people.

Deprescribing in older adults has been found to be difficult. We recently reviewed methods of deprescribing to reduce polypharmacy and the impact on prescribing and outcomes in older adults.⁶ While different interventions (for example pharmacy-based, physican-based and multidisciplinary-based interventions) can reduce medication exposure in older adults, the evidence for their clinical effectiveness and sustainability is limited and, where it is available, conflicting.

Moreover, time-limited trials of treatment may be suitable for safely discontinuing medications and guiding the deprescribing process in clinical practice.⁷ Further research is needed to determine the most feasible and effective strategies for discontinuing medications, and to provide a better understanding of the clinical benefits of deprescribing.