According to deprescribing.org, deprescribing is defined as “the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit. Deprescribing is part of good prescribing – backing off when doses are too high, or stopping medications that are no longer needed.”
Dania Al-Ani is the Continuing Competence Program Lead with the Alberta College of Pharmacy (ACP). In her previous role as a pharmacist with Covenant Health, she worked with internal medicine patients—many of whom had chronic conditions—once they were admitted to hospital. Deprescribing unnecessary or potentially harmful medications was a big part of her role.
“I would typically do a medication history for the patient and then reconcile those medications,” said Dania. “I would double check which medications were appropriate to be continued and which ones should be discontinued. At minimum, we would do this on admission and then when patients were discharged. Those are significant points during the patient’s stay at the hospital where a pharmacist can really make a difference. Also at discharge, we would provide seamless care by communicating with the patient’s community pharmacy team and their physicians to let them know if we had deprescribed anything. We informed them which medications were stopped and the reasons why, and whether they were stopped for a certain time or altogether, or if we were tapering a patient off a medication.”
As discussed throughout this edition of Full Scale, deprescribing medications, particularly for patients taking multiple medications, can have many benefits, particularly for those taking multiple medications.
“Some individuals suffer from an overwhelming ‘pill burden’ due to the sheer amount of medication they are taking. It’s difficult to keep them all straight,” said Dania. “Because of this burden, some individuals, unfortunately, just give up and stop taking their medications. Reducing their pill burden can help them adhere to the necessary medications that they should be taking.”
Deprescribing, says Dania, enables pharmacists to be proactive by preventing potential harm to patients. She adds it should be a consideration for pharmacists at every patient encounter.
“As we’re reviewing the benefits and risks of any medication—including over-the-counter medications—and natural health products, a pharmacist assesses the indication, effectiveness, safety, and adherence for every medication that a patient is taking,” said Dania. “During this assessment is when the pharmacist should consider if deprescribing is appropriate.”
Dania says another opportunity for deprescribing comes when community pharmacists are preparing comprehensive care plans for patients.
“When you are reviewing every medication a patient has been prescribed, that is a really good time to take a step back and say, ‘does this patient really need all these medications?’” she said. “Or when refilling a blister pack, which often includes at least five or more medications, that would be an opportunity to address whether the patient requires all of those medications.”
Prescriptions for specific drugs may also be an opportunity for pharmacists to consider deprescribing. Proton pump inhibitors (PPIs) are examples of drugs that are often overprescribed and invite unnecessary harm.
“A lot of times people think that PPIs are benign and just keep prescribing them for or dispensing them to their patients,” said Dania. “I think deprescribing PPIs could be a big role for pharmacists, especially now that we’re noticing that these drugs are associated with long-term adverse effects, such as reduced vitamin and mineral absorption, which can lead to bone loss, fractures, and other issues.”
Deprescribing is an important role that pharmacists have always played. In fact, ACP highlighted deprescribing as part of the reason why Albertans could benefit from pharmacist prescribing prior to that authority being granted in 2007. As deprescribing was viewed as part of prescribing, it was not explicitly included in ACP’s existing standards. However, ACP’s newly drafted Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT)—to be considered by Council for implementation in 2025—include deprescribing as a key concept.
“Even though deprescribing is not new, some pharmacists have questioned whether they can do it or not,” said Monty Stanowich, ACP’s Policy Lead and Compliance Officer. “Deprescribing has always been an option. The new standards provide clarity, a framework, and direction for pharmacists when deprescribing.”
In the new standards, deprescribing is particularly prominent in the section that covers additional prescribing authorization (APA).
“Deprescribing includes the same considerations as initiating a prescription and managing ongoing therapy,” said Monty. “This can include reducing a dose to the effective level for the patient—that’s managing care. Reducing a dose or taking someone off a drug uses the same skill set and assessment as starting a patient on a drug.”
Monty stresses that a pharmacist doesn’t have to have APA to participate in the deprescribing process.
“They should deprescribe if it’s appropriate, but they need to do it collaboratively with the prescriber,” said Monty. “If a patient had an allergic reaction to a medication, the expectation is the pharmacist would tell the patient to discontinue the drug immediately. But the pharmacist would also be expected to communicate with the prescriber and collaborate with them to find a solution. The same holds true of deprescribing—collaboration with a prescriber can be a valuable way to take a patient off a medication.”
A key domain of the new standards is providing person-centred care. This is especially true when deprescribing.
“A big part of being person centred is talking to the patient, their family, or their care givers and determining their goals of therapy,” said Dania. “Do they want to stop a medication or perhaps reduce the dose and see how it goes? What are their expected outcomes? Those are the kinds of questions pharmacists need to ask. It’s also important to collaborate with the patient’s healthcare providers, especially if it’s a controlled drug or an opioid where a pharmacist can’t initiate deprescribing on their own.”
If a pharmacist has decided that deprescribing is an appropriate measure, Dania says to ensure the following:
- Conduct a thorough patient assessment that includes considering how long a patient has been on the medication and checking if the medication that’s being prescribed requires tapering.
- Consider or recommend non-pharmacological therapies to the patient.
- Use evidence-based resources (some are provided below).
- Collaborate with and notify other health professionals as appropriate.
- Develop a detailed follow-up and monitoring plan.
- Complete documentation about the deprescribing plan.
Refer to our other Full Scale articles to learn more about deprescribing for seniors, advice from Choosing Wisely Canada, deprescribing antimicrobials, and how pharmacy students are learning about deprescribing.
Deprescribing resources
- Canadian Medication Appropriateness and Deprescribing Network (a video on overcoming the barriers to deprescribing)
- Deprescribing.org (a website with research and guidelines on deprescribing)
- Bruyere polypharmacy and deprescribing learning module
