Polipharmacy and deprescribing: practical recommendations

• Polypharmacy (the use of more than 5 prescription medications or the inappropriate use of medications in a patient) can induce more harm than benefit and requires periodic review to evaluate patient’s needs based on the therapeutic goal and to deprescribing medication no longer needed.
• The process of monitoring the treatment of the polymedicated patient, under the supervision of the health care team, consists of three basic interventions: medication review, shared decision-making and follow-up of treatment changes.
• Medication review should take place on a drug-by-drug basis, assessing needs, effectiveness, appropriateness and safety of medication.
• Decisions made at each stage of the review process should be based on the best evidence available and on specific deprescribing tools (STOPP/START, AGS Beers, Polypharmacy, MedStopper, etc.).
• During the review process, it could be useful to bear in mind medications with little therapeutic value, the cholinergic burden, medications that prolong the QT interval, or any adverse effects that could cause therapeutic cascade.
• Shared decision-making includes four steps: 1) introduce deprescribing options, 2) discuss risks and benefits for each option, 3) assess patient’s preferences, and 4) reach a decision with the patient.
• Along the shared decision-making process, it is important to establish a trusting doctor-patient relationship, using appropriate language, not forgetting it should be a two-way process, involving the patient and ensuring he/she understands the information provided.
• It is extremely important to prioritise which medication to deprescribe first, and to deprescribe one medication at a time.
• Follow-up is crucial to establish whether to discontinue medication completely or reduce the dose, or whether to reinitiate the medication that was withdrawn.
• Discontinuation from medications that involve tapering the dose need closer follow-up.