Deprescribing, a Sisyphean task?
The pessimistic claim “based on reasonably substantive evidence so far, it is unlikely that we are going to see major breakthroughs in deprescribing” deserves comment.(1)
Firstly, medication reconciliation is a long and bumpy road and finding a prudent middle ground to protect patient interests represents an immense tension. Nevertheless, the inappropriate polypharmacy in older people challenges common sense as this population derives not only less benefit from medications, due to multiple pathologies and limited life expectancy, but also more risk of medication-related harms. Worse, among 15 tools for deprescribing in the eldest only four have been tested in clinical conditions, all with very low-quality studies.(2) However, a simple tool is available for an easy beginning, the cornerstone for further success: the yearly list of “drugs to avoid” published by the independent drug bulletin Prescrire which is based on a rigorous procedure. These are a hundred of drugs with adverse effects that are disproportionate to their benefits or drugs superseded by others with a better harm-benefit balance.(3) This list permits easy persuasion of both the patient and the initial prescriber that the reconciliation is based on robust evidence. Drug regulatory agencies should be concerned by reconciliation too but they are going too fast for approval and too slow for withdrawal from the market.(4)
Secondly, some barriers are obvious (limited time to review medications, poor communication between prescribers or lack of respect of primary care physicians’ role as coordinators …) but cognitive biases cannot be overlooked. The question must not be “should the medication be stopped?” but “should this medication have been prescribed?” Withholding and withdrawing treatments must not be regarded as equivalent. Healthcare professionals widely perceive moral differences between withholding and withdrawing, finding it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold).(5)
Thirdly, deprescribing will remain a Sisyphean task, laboriously repetitive, if practitioners were not trained to prescribe according to Evidence Based Medicine rather than to rely on marketing hypes which are on a free ride.
The case of deprescribing shows evidence that quality improvement, the science of process management, is a challenge that still lies far ahead in the healthcare system!
1 Avery AJ, Bell BG. Rationalising medications through deprescribing. BMJ 2019;364:l570. 2 Thompson W, Lundby C, Graabaek T et al. Tools for deprescribing in frail older persons and those with limited life expectancy: A Systematic Review. J Am Geriatr Soc 2018. Online Oct 13. doi: 10.1111/jgs.15616.
3 Towards better patient care: drugs to avoid in 2018" Prescrire International 2018; 27 (192): 107-1 - 107-9 (Pdf, free) http://english.prescrire.org/en/AA26644A665789B5BD5C3814F73AE19D/Downloa...
4 Braillon A, Menkes DB. Balancing accelerated approval for drugs with accelerated withdrawal. JAMA Intern Med 2016;176:566-7.
5 Wilkinson D, Butcherine E, Savulescu J. Withdrawal aversion and the equivalence test. Am J Bioeth 2018. In press.
Competing interests: No competing interests