Is deprescription the cure for polymedication?

The use of medicines in the elderly poses many problems due to the physiological changes that occur in our bodies during the ageing process and the appearance of chronic diseases linked to them.

While drug therapy is one of the most important tools for disease control, in developed countries, polymedication* in older people is a major public health problem, both because of its high prevalence and rising trend, and because of its consequences for the individuals who are subjected to it. Many of the polymedicated individuals show a high rate of potentially inappropriate prescriptions and are therefore particularly at risk of suffering adverse drug reactions.

This is especially important for the most vulnerable patients, such as those with frailty, geriatric syndromes, decline in functionality, cognitive impairment, or a combination of these. The identification of fragile subjects and/or those with advanced chronic diseases will allow us to carry out a pharmacological approach focused on the group of people most vulnerable to iatrogenic medication and will enable decision-making to be adapted to each person's life situation.

In this context, the term "deprescribing" has emerged for the first time, a term which refers to the procedure aimed at reversing the adverse health effects caused by polymedication. One of the most widely used definitions is that formulated by Reeve and its collaborators, who refer to it as 'a process of withdrawing an inappropriate medicine, supervised by a health professional with the aim of managing the poly-pharmacy and improving results'.

There are different strategies for carrying out deprescription, although the most widespread are reviews of drug treatments based on explicit or implicit criteria. The explicit criteria focus on a list of potentially inappropriate drugs for older people, while the implicit criteria focus on clinical judgements where the person's entire therapeutic regime is evaluated, which helps to detect both potentially inappropriate prescriptions and unnecessary prescriptions, as well as those drugs with an unfavourable risk-benefit balance.

The different prescription strategies have led to a decrease in both the total number of medications and potentially inappropriate prescriptions in older people. Likewise, recent systematic reviews and meta-analyses based on studies of prescription suggest a decrease in mortality when interventions based on treatment reviews are used, although they do not provide conclusive data on other variables such as decrease in adverse drug reactions or decrease in the number of hospital readmissions.

The already known demographic tsunami makes it essential to use deprescribing strategies, as well as to continue with research studies in this field that allow the definition of appropriate intervention models in a larger, highly medicalised society that requires action by health professionals on an urgent basis.

(*) Definido en términos cuantitativos, como el consumo de 5 o más medicamentos crónicos al día de forma continuada durante al menos 3 meses.

Suggested readings:
Wastesson J.W., Morin, L., Tan E.C.K., Johnell, K. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opinion on Drug Safety 2018; 17(12), 1185-1196, DOI: https://doi.org/10.1080/14740338.2018.1546841

Espaulella-Panicota J, Molist-Brunet N, Sevilla-Sáncheza D, González-Bueno J et al. Modelo de prescripción centrado en la persona para mejorar la adecuación y adherencia terapéutica en los pacientes con multimorbilidad. Rev Esp Geriatr Gerontol 2017; 52(5), 278–281. DOI: https://doi.org/10.1016/j.regg.2017.03.002

Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine 2017; 38, 3–11. DOI: https://doi.org/10.1016/j.ejim.2016.12.021

Page AT., Clifford RM., Potter K, Schwartz D., Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol 2016; 82(3) 583–623. DOI: https://doi.org/10.1111/bcp.12975

Gutiérrez-Valencia, M., Martínez-Velilla N., Vilches-Moraga A. Polypharmacy in older people: time to take action. European Geriatric Medicine 2019; 10(1), 1-3. DOI: https://doi.org/10.1007/s41999-018-0140-5