Skip to Content

The Cochrane Library

Trusted evidence. Informed decisions. Better health.

Open menu

Scolaris Language Selector Scolaris Language Selector

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet

Scolaris Content Display Scolaris Content Display

Cochrane Special Collections

Achieving sustainable healthcare through deprescribing of unnecessary medications: making sense of the evidence

7 July 2022
Collapse all Expand all
Special Collection

People are living longer, have multiple chronic conditions, and are taking multiple concurrent medications (polypharmacy). Overtreatment with inappropriate or unnecessary polypharmacy can be problematic in any patient. One approach to mitigate overtreatment with polypharmacy is through deprescribing. Deprescribing is the process of identifying and discontinuing (or dose reducing) medications in which potential harms outweigh potential benefits within the context of an individual patient’s care goals, function, values, and preferences. In recent years, research into deprescribing has expanded rapidly, and this has greatly enabled efforts to implement deprescribing into clinical practice.

This Cochrane Library Special Collection provides an overview of Cochrane Reviews that have attempted to summarize the potential benefits and harms of deprescribing specific medications as well as to inform how to implement deprescribing across different settings and populations. These reviews highlight that deprescribing is likely feasible and safe and can lead to benefits in prescribing and clinical outcomes. However, they also highlight significant gaps in the literature and methodological challenges to both conducting deprescribing studies and systematic reviews of deprescribing.

This Collection is part of a series. See also De-implementation of low-value health care: resource prioritization in the COVID-19 pandemic era.

Cochrane Reviews of deprescribing of specific medication classes

These Cochrane Reviews aim to determine the benefits and harms of deprescribing specific drug classes (or therapeutic classes, such as antihypertensives). The purpose of these reviews is generally to inform whether it is appropriate to deprescribe drug classes in specific conditions and/or populations (i.e. whether the benefits outweigh the harms). Feasibility of discontinuation is also examined in some reviews, informed by the outcome of how many participants needed to restart the medication. These reviews mostly consider the ‘intervention’ of discontinuation versus continuation of individual medications. Several reviews include studies that attempted to taper the medications prior to cessation or conduct abrupt withdrawal. The included reviews focused on a variety of different medication classes, including both symptomatic and preventative medications.

Withdrawal or continuation of cholinesterase inhibitors or memantine or both, in people with dementia

Dementia is a progressive syndrome characterised by deterioration in memory, thinking and behaviour, and by impaired ability to perform activities of daily living. Two classes of drug ‐ cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and memantine ‐ are widely licensed for dementia due to Alzheimer's disease, and rivastigmine is also licensed for Parkinson's disease dementia. These drugs are prescribed to treat the symptoms in these and sometimes in other forms of dementia. There are uncertainties about the benefits and adverse effects of these drugs in the long term and in severe dementia, about effects of withdrawal, and about the most appropriate time to discontinue treatment. The aim of this review is to evaluate the effects of withdrawal or continuation of cholinesterase inhibitors or memantine, or both, in people with dementia on: cognitive, neuropsychiatric and functional outcomes, rates of institutionalization, adverse events, dropout from trials, mortality, quality of life and carer‐related outcomes.

Withdrawal of antihypertensive drugs in older people

Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Overall, the use of antihypertensive medications has led to reduction in cardiovascular disease, morbidity rates and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions, drug‐drug interactions and can contribute to increasing medication‐related burden. As such, discontinuation of antihypertensives may be considered and appropriate in some older people. The aim of this review is to investigate whether withdrawal of antihypertensive medications is feasible, and to evaluate the effects of withdrawal of antihypertensive medications on mortality, cardiovascular outcomes, hypertension and quality of life in older people.

Rapid versus slow withdrawal of antiepileptic drugs

The ideal objective of treating a person with epilepsy is to induce remission (free of seizures for some time) using antiepileptic drugs (AEDs) and withdraw the AEDs without causing seizure recurrence. Prolonged usage of AEDs may have long‐term adverse effects. Hence, when a person with epilepsy is in remission, it is logical to attempt to discontinue the medication. The timing of withdrawal and the mode of withdrawal arise while contemplating withdrawal of AEDs. This review examines the evidence for the rate of withdrawal of AEDs (whether rapid or slow tapering) and its effect on seizure recurrence. This review aimed to quantify risk of seizure recurrence after rapid (tapering period of three months or less) or slow (tapering period of more than three months) discontinuation of antiepileptic drugs in adults and children with epilepsy who are in remission, and to assess which variables modify the risk of seizure recurrence.

Down‐titration and discontinuation strategies of tumour necrosis factor–blocking agents for rheumatoid arthritis in patients with low disease activity

Anti-tumour necrosis factor (TNF) agents are effective in treating people with rheumatoid arthritis but are associated with (dose‐dependent) adverse effects and high costs. To prevent overtreatment, several trials have assessed the effectiveness of down‐titration compared with continuation of the standard dose. The aim of this review is to evaluate the benefits and harms of down‐titration (dose reduction, discontinuation, or disease activity‐guided dose tapering) of anti‐TNF agents on disease activity, functioning, costs, safety, and radiographic damage compared with usual care in people with RA and low disease activity.

Haloperidol discontinuation for people with schizophrenia

Schizophrenia is a disabling serious mental illness that can be chronic. Haloperidol, one of the first generation of antipsychotic drugs, is effective in the treatment of schizophrenia but can have adverse side effects. The effects of stopping haloperidol in people with schizophrenia who are stable on their prescription are not well researched in the context of systematic reviews. This review assessed the effects of haloperidol discontinuation in people with schizophrenia who are stable on haloperidol.

Withdrawal versus continuation of long‐term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia

Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in people with dementia although there is uncertainty about the effectiveness of their long‐term use for this indication and concern that they may cause harm, including higher mortality. When behavioural strategies have failed and treatment with antipsychotic drugs is instituted, regular attempts to withdraw them have been recommended in guidelines. Physicians, nurses and families of older people with dementia may be reluctant to stop antipsychotics, fearing deterioration of NPS. This review evaluates whether withdrawal of antipsychotic agents is successful in older people with dementia and NPS in primary care or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older participants with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on participants' behaviour and assess safety.

Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn's disease

Crohn's disease is a chronic, relapsing and remitting disease of the gastrointestinal tract that can cause significant morbidity and disability. Current treatment guidelines recommend early intervention with immunosuppressant or biological therapy in high‐risk patients with a severe disease phenotype at presentation. The feasibility of therapeutic de‐escalation once remission is achieved is a commonly encountered question in clinical practice, driven by patient and clinician concerns regarding safety, adverse events, cost and national regulations. Withdrawal of immunosuppressant and biologic drugs in patients with quiescent Crohn's disease may limit adverse events and reduce healthcare costs. Alternatively, stopping these drug therapies may result in negative outcomes such as disease relapse, drug desensitization, bowel damage and need for surgery. This review assessed the feasibility and safety of discontinuing immunosuppressant or biologic drugs, administered alone or in combination, in patients with quiescent Crohn’s disease.

Statin withdrawal in people with dementia

There are approximately 24 million people worldwide with dementia; this is likely to increase to 81 million by 2040. Dementia is a progressive condition, and usually leads to death eight to ten years after first symptoms. End‐of‐life care should emphasise treatments that optimise quality of life and physicians should minimise unnecessary or non‐beneficial interventions. Statins have become the cornerstone of pharmacotherapy for the management of hypercholesterolaemia but their ability to provide benefit is unclear in the last weeks or months of life. Withdrawal of statins may improve quality of life in people with advanced dementia, as they will not be subjected to unnecessary polypharmacy or side effects. However, they may help to prevent further vascular events in people of advanced age who are at high risk of such events. This review aims to evaluate the effects of withdrawal or continuation of statins in people with dementia on cognitive outcomes, adverse events, behavioural and functional outcomes, mortality, quality of life, vascular morbidity, and healthcare costs.

Antihypertensive withdrawal for the prevention of cognitive decline

Clinical trials and observational data have variously shown a protective, harmful or neutral effect of antihypertensives on cognitive function. In theory, withdrawal of antihypertensives could improve cerebral perfusion and reduce or delay cognitive decline. However, it is also plausible that withdrawal of antihypertensives may have a detrimental effect on cognition through increased incidence of stroke or other vascular events. This review assessed the effects of complete withdrawal of at least one antihypertensive medication on incidence of dementia, cognitive function, blood pressure and other safety outcomes in cognitively intact and cognitive impaired adults.

Cochrane Reviews of interventions to achieve deprescribing specific medication classes

The reviews in this section focus on a specific drug class in a specific condition or population – however as distinct from the previous section the focus is generally more around determining how to achieve or support deprescribing in clinical practice. Intervention types vary significantly between the reviews from focusing on the approach to deprescribing such as abrupt vs tapering vs intermittent use, to use of substitution, non-pharmacological treatments (e.g. massage for pain) or low-touch interventions (such as sending letters to the GP to review antidepressant treatment). They may also report on clinical outcomes (i.e. benefits and harms).

Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long‐term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long‐term antidepressant prescriptions had no evidence‐based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high‐certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long‐term antidepressants. This review assesses the effectiveness and safety of approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults.

Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users

Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. This review aimed to assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use.

Interventions for the reduction of prescribed opioid use in chronic non‐cancer pain

People with chronic non‐cancer pain who are prescribed and are taking opioids can have a history of long‐term, high‐dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple, unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain. The aim of this review is to investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non‐cancer pain in adults compared to controls.

Deprescribing versus continuation of chronic proton pump inhibitor use in adults

Proton pump inhibitors (PPIs) are a class of medications that reduce acid secretion and are used for treating many conditions such as gastroesophageal reflux disease, dyspepsia, reflux esophagitis, peptic ulcer disease, and hypersecretory conditions (e.g. Zollinger‐Ellison syndrome), and as part of the eradication therapy for Helicobacter pylori bacteria. However, approximately 25% to 70% of people are prescribed a PPI inappropriately. Chronic PPI use without reassessment contributes to polypharmacy and puts people at risk of experiencing drug interactions and adverse events (e.g. Clostridium difficile infection, pneumonia, hypomagnesaemia, and fractures). The aim of this review is to determine the effects (benefits and harms) associated with deprescribing long‐term PPI therapy in adults, compared to chronic daily use (28 days or greater).

Deprescribing of chronic benzodiazepine receptor agonists for insomnia in adults

This is a protocol for a review that will assess the benefits and harms of deprescribing benzodiazepine receptor agonists (BZRAs) in comparison with continued BZRA use, and will assess the benefits and harms of deprescribing BZRAs in comparison with usual care.

Cochrane Reviews of interventions which include deprescribing activities as part of reducing polypharmacy or improving appropriateness of medication use

These reviews now step away from being specific to drug classes, and may also not be specific to deprescribing outcomes. The reviews highlighted here examine different interventions to optimise medication use (in general), targeting specific populations and/or settings. The reviews include studies that report on changes to medication use, which may include number of medications and/or appropriateness of medication use. Three of these reviews were featured in a quick round up of reviews about evidence to address overprescribing.

Interventions to improve the appropriate use of polypharmacy for older people

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This review determines which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication‐related problems in older people.

Interventions to optimise prescribing for older people in care homes

There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. The objective of the review was to determine the effect of interventions to optimise overall prescribing for older people living in care homes.

Medication review in hospitalised patients to reduce morbidity and mortality

Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug‐related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes. This review examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care.

Effect of outpatient pharmacists' non‐dispensing roles on patient outcomes and prescribing patterns

The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counselling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist‐provided patient care on health‐related outcomes. Prior reviews have primarily focused on in‐patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This review examines the effect of outpatient pharmacists' non‐dispensing roles on patient and health professional outcomes.

About this Special Collection

Acknowledgements

This Special Collection project was developed by Dr Emily Reeve, BPharm (Hons), PhD (University of South Australia, and Monash University, Australia; Chair Elect of the Australian Deprescribing Network (ADeN)) and Associate Professor Danijela Gnjidic, BSc (Hons), PhD, MPH (The University of Sydney, Australia; ADeN Executive Committee Member) with support from Dina Muscat Meng (Cochrane Sustainable Healthcare, Cochrane Denmark, Cochrane Sweden) and Minna Johansson (Cochrane Sustainable Healthcare, Cochrane Sweden). The contributors wish to extend their thanks to all the people in Cochrane who generously contributed to help produce and disseminate this Special Collection.

Image credit

Mint Images / Getty Images

Contact

Cochrane Library editorial office: [email protected]

Close
Review tools & navigation