Deprescribing starts with shared decision making

Any doctor will tell you that prescribing a medication is relatively easy. You simply input the prescription into the electronic medical record, the patient gets the prescription, fills it, and takes the drug. 

But what if you want a patient to stop taking a drug they’ve been previously prescribed? There are many reasons a doctor may want to do this – perhaps the patient was prescribed the drug in the hospital and wasn’t meant to take it long-term, or maybe the doctor realizes the patient is taking two drugs that could cause an adverse reaction. With our country’s rate of polypharmacy nearly doubling since 2000, clinicians are increasingly seeing patients who are taking unnecessary medications. 

Unfortunately, it’s much easier to prescribe than to “deprescribe.” Doctors have little time and few tools to review their patients’ medications, and are often reluctant to challenge the decisions of other clinicians who originally prescribed the medication. 

Dr. James McCormack, pharmacist and professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia, sees deprescribing as a symptom of a larger problem – the lack of real shared decision making in medicine. The guidelines and tools currently available for deprescribing often use a “one-size-fits-all” approach, simply giving a list of “bad drugs” for doctors to deprescribe. But these tools are only marginally helpful because they don’t take into account patient preferences, conditions, or the effects of different doses, says McCormack.

“It comes down to changing our fundamental thought process that the doctor says what’s good or bad for the patient, and the patient follows orders,” says McCormack. Instead, we need to have conversations with patients about the absolute risks and benefits of medications, to understand and help them reach their goals.

“There are very few really bad drugs, we just use them badly”

For example, clinicians debate whether statins are being prescribed too much or not enough. The question is not whether statins are “good” or “bad” drugs, but whether an individual patient would rather have a slightly lower (1-2%) risk of heart attack or stroke, or avoid the potential side effects, says McCormack. And this decision cannot happen without a discussion about the patient’s preferences and needs. 

The current deprescribing framework also ignores the importance of dose. “Most of the adverse effects of medications are dose-related,” says McCormack, “Only the patient can really figure out what dose is right for them, which is why the deprescribing process has to be done individually.”

Implementing shared decision making is much more ambitious than creating universal deprescribing guidelines, but McCormack insists that it is necessary to protect patients from the risks of inappropriate prescribing. “If deprescribing were easy, we would have already done it,” says McCormack, “It’s not easy but it can be done.”