Deprescribing in primary care

Opening Vignette Madam Lim, a 75-year-old retiree, visited your clinic for follow-up of hypertension, hyperlipidaemia, and bilateral knee osteoarthritis after bilateral total knee replacement one year ago. She is currently on losartan 25 mg OM, atenolol 25 mg OM, amlodipine 2.5 mg OM, atorvastatin 20 mg ON, paracetamol 450 mg/orphenadrine 35 mg 2 tabs TDS/PRN pain, diclofenac 50 mg TDS/PRN pain, omeprazole 20 mg BD, Neurobion® 1 tab OM, calcium 450 mg/vitamin D 200 IU 2 tabs OM, and glucosamine 500 mg TDS. She reported experiencing pill fatigue from her high pill burden and admitted to skipping some pills out of concern for her kidneys. You conducted a medication review to evaluate whether any of her medications could be safely deprescribed.WHAT IS DEPRESCRIBING? Deprescribing is the “systematic process of identifying and discontinuing medications in instances in which existing or potential harms outweigh existing or potential benefits, within the context of an individual patient’s care goals, current level of functioning, life expectancy, values and preferences.”[1] It is not intended to deny effective treatment to patients who are likely to benefit, but rather to reduce or eliminate the risk of harm from unnecessary medications. Deprescribing is a proactive process, unlike reactive discontinuation of a medication following an adverse drug reaction. It is initiated by or performed under the supervision of a healthcare professional, rather than being undertaken independently by the patient. A patient’s care goals, level of functioning, life expectancy, values and preferences are dynamic parameters that change over time. Therefore, deprescribing is frequently employed when there are significant changes in these parameters, such as in geriatric and end-of-life settings. HOW RELEVANT IS THIS TO MY PRACTICE? Deprescribing is particularly important in the setting of polypharmacy, commonly defined as the concurrent use of five or more medications.[2] Some authors have also described the goal of deprescribing as managing polypharmacy and improving outcomes.[3] With a rapidly ageing population and a growing burden of chronic disease in Singapore, an increase in the prevalence of polypharmacy is to be expected.[4] Polypharmacy is associated with higher risks of adverse drug events and drug–drug interactions, increased mortality, nonadherence to essential medications,[4] and greater healthcare costs. A 2019 study found that the prevalence of polypharmacy among community-dwelling elderly in Singapore was 14.5%.[4] A 2023 study reported a prevalence of 35% among polyclinic patients in Singapore.[5] Polypharmacy is a clinical challenge because the healthcare system is geared towards starting medications rather than reducing or stopping them, and guidelines typically include recommendations for initiating medications but not for stopping them.[6] Deprescribing is important in the setting of older adults because of changes in pharmacodynamics and pharmacokinetics of each medication with ageing, the weaker evidence of medication effectiveness in older or frail patients, and the possible changes in goals of treatment at this stage of life.[6] A 2020 meta-analysis found a prevalence of 33% of potentially inappropriate prescribing among older persons, contributing to 7.7%–17.3% of adverse outcomes in primary care.[7] A local study in 2018 reported that the most prevalent potentially inappropriate medication in Singapore was long-term proton-pump inhibitors without documented indication (45.7%), followed by strong anticholinergic agents (27.6%).[8] Deprescribing inappropriate or harmful medications can potentially prevent adverse effects from occurring, optimising patient safety [Box 1]. It can also reduce the risk of drug–drug interactions and nonadherence to essential medications, and lessen pill burden, potentially improving patients’ quality of life. As a corollary, deprescribing may reduce healthcare costs directly by lowering patients’ medication expenses and indirectly by decreasing the risk of complications from adverse drug effects.Box 1: Potential adverse effects of medications frequently considered for deprescribing.Deprescribing is particularly important in patients with severe dementia, end-stage organ failure or terminal cancer, where the potential benefit of medications may be limited due to reduced life expectancy, diminished quality of life and changes in treatment goals at advanced stages of disease. WHAT CAN I DO IN MY PRACTICE? Given the high number of chronic patients managed by family physicians in both public and private healthcare settings, family medicine is well-placed to initiate the process of deprescribing. Furthermore, many family physicians have access to the National Electronic Health Record (NEHR), allowing them to view medications prescribed from multiple sources. The longitudinal relationship of the family physician with the patient can also be leveraged to support this process.[6] Steps to deprescribing With reference to several deprescribing protocols,[1,2,6] the process of deprescribing can be divided into six steps [Box 2]. The steps to deprescribing may appear simple, but performing them well requires good background knowledge of each medication and evidence of its benefits and harms in relation to the patient’s clinical condition, prioritisation skills, good communication with the patient and/or family, and technical knowledge of down-titration schedules. It is essential for healthcare professionals to be mindful that the deprescribing process is patient-centred, especially during shared decision-making with the patient and/or family.Box 2: Steps to deprescribing.Screening tools such as the American Geriatrics Society Beers Criteria 2023 and the STOPP/START criteria (Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert doctors to Right Treatment) can assist in identifying inappropriate medications in older patients. However, although these tools are widely used in research, applying them in primary care is challenging and time-consuming.[10] The Beers criteria also include medications that may be appropriate in some situations (e.g. dipyridamole, oxybutynin and doxazosin).[10] Therefore, these tools should not substitute proper clinical judgement. Deprescribing.org (Canadian-based) has well-developed guidelines for desprescribing proton-pump inhibitors (PPIs), antihyperglycaemics, antipsychotics, benzodiazepine receptor agonists, cholinesterase inhibitors and memantine.[11] A local article by Teh el al.[12] also provides recommendations on deprescribing PPIs. Primary Health Tasmania (Australian-based) provides guidelines covering a wider range of medications, including allopurinol, anticholinergics, anticoagulants, antiepileptics, antihyperglycaemics, antihypertensives, antiplatelets, antipsychotics, benzodiazepines, bisphosphonates, cholinesterase inhibitors, gabapentinoids, glaucoma eyedrops, inhaled corticosteroids, long-acting nitrates, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, PPIs, statins, and calcium/vitamin D supplements.[13] Before adopting these guidelines in its entirety, it is prudent to consider how they align with the unique needs of the individual patients and how they can be applied within the framework of existing local clinical practice guidelines and Agency for Care Effectiveness Clinical Guidelines. Specialist’s input may sometimes be sought before certain medications such as long-acting nitrates are deprescribed. In addition to identifying clinical situations with a high priority for deprescribing, healthcare providers should also concurrently establish the goals of care with the patient, caregiver and/or main spokesperson to guide the deprescribing process. For example, the goals of deprescribing to reduce polypharmacy and improve adherence in an 80-year-old patient may differ from those in a patient with metastatic cancer. Two clinical scenarios should prompt the prescriber to consider deprescribing: the prescribing cascade and legacy prescribing. The prescribing cascade describes medications prescribed to counter the adverse effects of another medication.[1] An example is gastroprotective agents prescribed to patients on NSAIDs. The prescribing cascade is frequently preventable. Routine review of all medications a patient is taking — including those prescribed by other general practitioners, or purchased overseas or over the counter and not recorded in medical notes — enables clinicians to identify drugs that may be contributing to the presenting complaint and to avoid initiating additional medications to counter side effects. For example, a patient presenting with parkinsonian symptoms after being started on antipsychotics, or a patient presenting with constipation after being prescribed anticholinergics, can be better managed if the doctor is aware of the medication history. Legacy prescribing, on the other hand, refers to the prescribing of medications beyond the duration of their usual effectiveness or recommended periods.[14] For example, antidepressants or PPIs that are prescribed for more than 2 years, bisphosphonates that are prescribed for more than 5 years, or dual-antiplatelet therapy that is prescribed for more than a year. One way to prevent legacy prescribing is to inform the patient of the expected duration of treatment and document this clearly in the clinical notes at the time of prescribing a new medication. While it may not be possible to predict the exact duration of treatment, providing general guidance to patients and documenting it in clinical notes can lay the foundation for future conversations about deprescribing.[15] When undertaking deprescribing, medications can be broadly grouped into two categories, although some may fall into both.[1] The first category comprises disease and/or symptom control medications. These medications control active disease and symptoms and maintain quality of life (e.g., analgesics, antihistamines, glucosamine, PPIs). As an abrupt discontinuation of these medications may result in patients becoming symptomatic, a tapering regimen with close monitoring is advisable. The second category comprises preventive medications, which are prescribed to prevent future morbidity and mortality (e.g., direct oral anticoagulants, statins, warfarin, bisphosphonates). Patients may not immediately become symptomatic when these medications are discontinued. However, as they are intended to prevent a major event associated with significant morbidity and mortality, it is important to engage in a risk–benefit conversation with the patient and/or family before deprescribing. Key considerations to guide this conversation include the medication’s number needed to treat and time to benefit,[16] as well as the patient’s expected life expectancy and quality of life. When discussing deprescribing with the patient and/or family, the language used is critical to achieving shared decision-making.[15] It is important to convey that deprescribing is based on a perceived or calculated favourable risk–benefit ratio, will be closely monitored, and may involve redefining goals of care to optimise patient outcomes. Patients and their families should not feel that they are being abandoned, or that their medications are being withdrawn without their consent. Likewise, patients should also be discouraged from stopping medications independently, and adherence to remaining medications should be reinforced. BARRIERS TO DEPRESCRIBING A local study in 2018 identified common provider and system-related barriers to deprescribing in primary care.[8] These barriers, along with patient-reported barriers,[17] are summarised in Box 3.Box 3: Common barriers to deprescribing.Contrary to the belief of some healthcare providers, patients and caregivers can be quite open to deprescribing. In a 2020 study conducted in Singapore, 83% of older adults and 87.1% of caregivers reported willingness to stop one or more medications if advised by the doctor.[18] In the same study, 72.4% of older adults did not feel that a recommendation to stop a medication meant that their doctor was giving up on them, and 60.1% of caregivers did not perceive agreeing to stop a medication as giving up on their care recipient.[18] Some of these barriers can be readily overcome, such as improving communication between family physicians and specialists through written memos to patients, direct emails or messaging applications (e.g., Microsoft Teams). Others may be more challenging, requiring ongoing education of healthcare providers, patients and the public, as well as systemic changes to the healthcare environment (e.g., longer consultation times). FUTURE DEVELOPMENT Deprescribing can be incorporated into clinical practice through the following strategies: Education and training of doctors: Doctors should be educated on the importance of deprescribing as an integral part of good clinical care, including the principles and steps involved. This can be achieved through continuing medical education programmes within the clinic or institution. Collaboration with pharmacists: Deprescribing workflows can be co-developed with clinic pharmacists for clinically relevant scenarios. Pre-consultation medication reconciliation services can be used to review the appropriateness of a patient’s medications before the doctor’s consultation, highlighting issues for subsequent discussion with the patient or caregiver.[8] Medication reviews by pharmacists or doctors can also be scheduled at stipulated intervals (e.g., annually), with sufficient time allocated for each review. Pharmacists can also be empowered to initiate the deprescribing process. A local study in 2017 found that deprescribing interventions initiated by pharmacists for inpatients aged over 65 had a physician acceptance rate of 77.9%.[19] Computerised decision support: Deprescribing alerts should be incorporated into electronic medical record systems to alert clinicians of clinical scenarios that may warrant deprescribing. Electronic prescribing systems should also highlight any high-risk or potentially inappropriate medications that should be considered for deprescribing, especially when prescribed beyond a reasonable duration, and suggest deprescribing regimens for clinicians’ reference. Proper clinical documentation: The expected duration of a new prescription and any deprescribing attempts should be clearly documented in clinical notes. This will facilitate communication with subsequent doctors caring for the patient and assist in the planning, continuation or completion of the deprescribing process. Clinical audits: Audits can ascertain the prevalence of inappropriate medications being prescribed for various clinical scenarios to encourage deprescribing. Development of local deprescribing guidelines and algorithms: On the national level, local guidelines and algorithms for deprescribing should be developed in collaboration with pharmacists, geriatricians, palliative medicine specialists and other specialties to guide primary care physicians in different clinical scenarios. TAKE HOME MESSAGE Deprescribing is a patient-centred process of systematically identifying and discontinuing medications that may cause more harm than benefit, guided by the patient’s goals and preferences. Deprescribing is most relevant in geriatrics, palliative care, and in the setting of polypharmacy. It can reduce pill burden, healthcare costs, the risk of drug–drug interactions, nonadherence to essential medications, and improve quality of life. Primary care providers play a key role in initiating and guiding the deprescribing process due to their long-term relationship with patients. Deprescribing involves identifying high-priority clinical situations, reviewing current medications, assessing their risks and benefits, deciding on the order of withdrawal, and communicating, planning and implementing a regimen through shared decision-making. Important considerations for deprescribing include avoiding prescribing cascades and addressing legacy prescribing. Symptom-control medications should be tapered with close monitoring; preventive medications require detailed risk–benefit discussions before stopping. Barriers to deprescribing exist at the levels of the healthcare provider, patient and healthcare system. Potential enablers to deprescribing include physician education and training, collaboration with pharmacists, enhanced electronic prescribing systems, proper clinical documentation, clinical audits, and local guidelines and algorithms. Closing Vignette Further history revealed that Madam Lim’s knee pain had significantly reduced after surgery and physiotherapy. She has no history of dyspepsia, gastro-oesophageal reflux disease, oesophagogastroduodenoscopy, gastrointestinal bleeding, neuropathy or limb numbness. Her recorded home blood pressure (BP) was 100–110/55–70 mmHg (heart rate [HR] 55–65 beats/min), and she had no postural giddiness. Deprescribing was discussed with Madam Lim and her family, and a shared decision was made to stop atenolol, paracetamol/orphenadrine, diclofenac, omeprazole, glucosamine and Neurobion. You further reinforced the importance of continuing her remaining medications to enhance outcomes. At the one-month review, her home BP was 115–125/60–75 mmHg (HR 60–75 beats/min). She reported no knee pain after stopping analgesics and expressed gratitude for the medication review.Acknowledgement We would like to acknowledge Dr Siddharth Reddy Padigepati for his contributions to the case vignette. Financial Support and Sponsorship Nil. Conflicts of interest How CH is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 22 November 2025

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