What’s old is new again. Hipster beards are so in, they’re out, and where we used to simply cease medications—we now deprescribe them.
The art of commencing medicinal herbs dates back to Neolithic times. The art of stopping them began about a week later.
Probably why Hippocrates had to remind us to do no harm.
With this history, we gen-dinosaur GPs have recently been scratching our beardy chins wondering how we missed the memo that deprescribing is now a ‘thing’.
Mind you; old or new, learning how to stop medication is critical for patient care. And hopefully, now we have a word for it, tomorrow’s deprescribers will do it smarter and harder than we ever did.
Our generation received no explicit teaching, gleaning what we could from our mentors and, no doubt, from our mistakes.
A recent article in The Conversation highlights the dubious practice of using one medicine to counter the side effects of another. This is fine if the first medicine is vital and the second makes the first tolerable. But more often the medicine cabinet rivals a lolly shop, and vague side effects are ubiquitous.
For the 10 per cent of Australians over 65 years taking 10 or more medications, an antacid or antinauseant may just reflect that the stomach is coping with nine other pills. I’d argue sometimes even the antidepressant is a product of a similar prescribing cascade.
A tenth of all hospital admissions in the elderly are due to an adverse drug reaction. Some result from errors, but you have to wonder how many are due to set-and-forget prescribing.
Judging when to cease a medication is by no means simple. We keep writing repeats when we probably shouldn’t, for many reasons; I’ll mention two.
First, we are loathe to stop medicines started by others. This makes some sense—the specialist or other GP probably had good reason to prescribe at the time.
Yet right now the patient is seeing me. They trust that when I double-click ‘repeat’, I have assessed that each of their current load (or overload) of medicines remains necessary. That, among the maelstrom of chemicals interacting in their bloodstream, each is probably still doing more good than harm.
I must act as their advocate, gatekeeper, master planner. In short, their GP.
Second, we often outsource our medicines narrative to pharmaceutical companies. Their job is to focus discussion on the scientific minutiae distinguishing their pill from their rival’s.
No matter how smart or sceptical we are, the rep’s narrative keeps our eyes on the ‘little picture’ detail. A trick we won’t notice unless we look up. No amount of reps and pharma dinners will ever mention deprescribing, a concept understandably untrammelled by pharma research.
We need to reassert control over our own narrative in primary care.
We GPs, along with ‘big picture’ general physicians and geriatricians, are best placed to become experts in deprescribing. So maybe it is quite a useful word after all.
- A Tasmanian primary care website listing drug classes to deprescribe, or see their pdf deprescribing guide
- A Canadian deprescribing website
- A NZ guide to stopping medicines in older people
- An Australian study in aged care facilities where stopping 4-5 medications per resident improved survival (not statistically sig’t, p=0.16) without causing problems.