Doctors learn quite a bit about prescribing medications but not quite as much about deprescribing them. Consequently, many patients wind up on numerous medications, some of which they may no longer need.
“Nearly one-half of older adults take five or more medications, and as many as one in five of these prescriptions is potentially inappropriate,” wrote two pharmacists in an editorial in American Family Physician.
“Polypharmacy is a clinical challenge because the health care system is geared toward starting medications, not reducing or stopping them, and guidelines typically include recommendations for initiating medications, but not stopping them,” they wrote.
Just as there is an art and science to prescribing medications, there’s a complementary art and science to deprescribing them. With that in mind, here are five medications that doctors may consider deprescribing—with an eye toward individualized therapy, of course.
Proton pump inhibitors
Proton pump inhibitors (PPIs) are widely prescribed, rarely deprescribed, and commonly purchased over the counter. They’re frequently used without medical indication and for much longer than needed. The general indication is for only 2 weeks, not long term. Though PPIs have traditionally been considered safe, they’ve since been linked to serious adverse events—including cardiovascular disease (CVD), pneumonia, osteoporotic fractures, Clostridioides difficile infections, acute kidney injury, chronic kidney disease, dementia, upper gastrointestinal cancer, and death.
“Given the millions of people who take PPIs regularly, this translates into thousands of excess deaths every year,” said nephrologist Ziyad Al-Aly, MD, Clinical Epidemiology Center, Department of Veterans Affairs St. Louis Health Care System, St Louis, MO, whose research team linked PPIs to greater mortality.
“Our study suggests the need to avoid PPIs when not medically necessary,” he added. “For those who have a medical need, PPI use should be limited to the lowest effective dose and shortest duration possible.”
Statins are among the most commonly prescribed drugs, with more than 35 million Americans taking them. An estimated two-thirds of these patients take statins for the primary prevention of CVD.
Do all these millions of people really need to take this medicine? It’s a hotly debated topic.
Last year, the authors of an analysis of systematic reviews investigated the relationship between taking statins and future risk of CVD. They concluded that there was limited evidence on the effectiveness of using statins for the primary prevention of CVD.
In a related study, the same researchers found that the number needed to treat to prevent one major vascular event was 400 for low-risk patients compared with ≤ 25 for very high-risk patients.
“One would have to question whether some patients, who may achieve very small reductions in risk of [CVD] by taking statins, would agree to take this medication were they fully informed,” said the lead author of the studies.
When deciding whether to prescribe statins, clinicians should consider individual baseline risk, absolute risk reduction, and whether the risk reduction justifies the potential harms of taking a daily medicine for life, the authors recommended.
Just about all doctors would agree that antibiotic overprescribing is a problem, and yet the problem continues. Of the estimated 154 million antibiotic prescriptions written each year in US outpatient settings, at least 30% are unnecessary, according to the CDC. Likewise, 20% to 50% of antibiotics prescribed in US acute care hospitals are unnecessary or inappropriate.
According to the FDA, more than 70% of the bacteria responsible for the 2 million infections acquired in US hospitals each year are resistant to at least one commonly used antibiotic.
Beyond antibiotic resistance, the risks of antibiotic overuse or overprescribing include increases in disease severity, disease length, health complications, adverse effects, mortality risk, healthcare costs, re-hospitalization, and medical treatment for health problems that might have otherwise resolved on their own.
Antimuscarinic drugs for overactive bladder
Antimuscarinic medications for overactive bladder are not especially effective. They also have a high rate of adverse effects. As a consequence of these two factors, patients commonly discontinue these drugs (or want to discontinue them).
“In line with published reports, a major reason for patients not restarting treatment was that they experienced no difference in symptoms on or off treatment,” wrote pharmacist Seema Gadhia in The Pharmaceutical Journal.
In terms of efficacy, antimuscarinic agents restored continence in only about 10% of patients, researchers reported in a systematic review published in Annals of Internal Medicine. For example, in pooled analyses, continence was restored in 8.5% of patients taking tolterodine (Detrol), 10.7% taking solifenacin (Vesicare), 11.4% taking oxybutynin (Ditropan), 11.4% taking trospium (Sanctura), and 13.0% taking fesoterodine (Toviaz).
These relatively low efficacy rates compel an uncommonly high number of patients to discontinue antimuscarinics.
Antimuscarinics also have a high risk of adverse side effects that limit their tolerability. The most common adverse effects include dry mouth, constipation, blurred vision, somnolence, and dizziness. Long-term use of antimuscarinics has also been associated with an increased risk of cognitive impairment and mortality in older adults.
Benzodiazepines and related “Z” drugs—such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata)—are sedative-hypnotics commonly prescribed to treat anxiety, mood disorders, depression, and insomnia, as well as seizures. In fact, they’re very commonly prescribed—over 5% of US adults are on benzodiazepines, according to one estimate. (A more recent calculation places their use at over 12%.) And benzodiazepine use is growing, with prescription rates nearly doubling between 2003 and 2015—a pattern similar to that of opioids.
Misuse of benzodiazepines is also common, with 5.3 million Americans taking benzodiazepines in a way not prescribed by their physicians. Misuse includes taking the drugs without a prescription, taking higher doses than prescribed, and taking them more frequently or for longer than prescribed. As to the latter, benzodiazepines are intended to be used for fewer than 14 days but chronic use (more than 120 days) is common. This is particularly true among older adult benzodiazepine users (aged 60-80 years), 31.4% of whom were found to be taking the drug long term. Notably, most prescriptions for benzodiazepines used long term were written by non-psychiatrist prescribers.
Sadly, overdoses and deaths associated with benzodiazepines are also common, with the number of benzodiazepine-related deaths increasing from 135 in 1999 to 11,500 in 2017. Indeed, nearly one-third (31%) of all fatal drug overdoses in 2013 involved benzodiazepines.
Worse yet, benzodiazepine misuse is strongly associated with misuse and abuse of prescription opioids, as one-third of opioid-related overdoses and one-fifth of opioid-related deaths also involve benzodiazepines.
“The risks of benzodiazepines have attracted far less attention than those of opioids,” wrote Keith Humphreys, PhD, professor and section director for Mental Health Policy, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, in a Washington Post article.
Dr. Humphreys added that “many health-care organizations, physicians and patients remain unaware of the country’s benzodiazepine problem. That must change if we are to reverse the rising tide of drug overdose deaths.”
Evidence-based clinical practice guidelines are available to help clinicians deprescribe benzodiazepines.