Deprescribing: When Taking Fewer Medications Is Better

Your pill organizer has more slots filled every year. One drug was added after a hospital stay, another by a specialist, and another to treat a side effect. Nobody has looked at the whole list in a while. You may wonder whether you still need all of them.

That is exactly the question deprescribing asks. This guide explains what it is, why it matters, and how it is done safely.

What deprescribing means

Deprescribing is a planned process of reducing or stopping medicines when the possible harms now outweigh the benefits. A clinician leads it, together with you, and follows up after each change.[1]

Medicines are often started for good reasons. Over time, things change:

• The original problem may have resolved.
• You may be older, and your kidneys and liver may clear drugs more slowly.
• New research may show smaller benefits than once thought.
• Your goals may have changed, for example from long-term prevention to comfort and daily function.
• A new symptom may be a side effect of a drug you already take.

The term polypharmacy is often used for taking five or more medicines. More medicines mean more chances for side effects and interactions. Adverse drug events send many people to emergency departments each year, and older adults are at highest risk.[5]

What your doctor looks at

A structured review

Experts describe a stepwise approach:[1]

• Make a full list of every medicine and the reason for each one.
• Consider your overall risk of harm from drugs, based on age, the number of drugs, and your health.
• Check each drug: is it still needed, and do its benefits still outweigh its risks?
• Rank drugs to stop, starting with those that have the most harm and least benefit.
• Make one change at a time, and follow up closely.

Tools clinicians use

The American Geriatrics Society Beers Criteria list medicines that are often risky in adults 65 and older. It also lists risky drug combinations and drugs to adjust for kidney function.[2] Examples include:

• Benzodiazepines and "Z-drug" sleeping pills, which raise the risk of falls, fractures, confusion, and car crashes.
• Strong anticholinergic drugs, such as diphenhydramine and some bladder and allergy drugs, which can cause confusion, constipation, and urine retention.
• Long-term use of PPI heartburn pills without a clear reason.
• Some diabetes drugs that cause low blood sugar.

Clinicians in Canada and the US use the Beers Criteria, and many also use a European tool called STOPP/START. Canadian teams have published evidence-based deprescribing guidelines for specific drug groups. One example is the guideline for PPIs published in Canadian Family Physician.[4]

What the evidence shows

In a Canadian trial called EMPOWER, older adults who had taken benzodiazepines for a long time received a brochure. It explained the risks and showed a tapering plan. After 6 months, 27% of people who got the brochure had stopped the drug, compared with 5% of people who did not. Another 11% had lowered their dose.[3] Information given directly to patients led to real conversations and real change.

Why you should never stop on your own

Some medicines cause withdrawal or rebound effects if they stop suddenly. They need a slow, planned taper. Examples include:

• Benzodiazepines and other sleeping pills.
• Antidepressants.
• Beta blockers for the heart.
• Steroid pills, such as prednisone, after long use.
• Seizure medicines.
• Opioid pain medicines.

Other drugs, such as blood thinners, protect you from serious events even when you feel well. Stopping them without a plan can be dangerous. Your clinician and pharmacist can design a safe schedule.

How to start the conversation

• Bring all your medicine bottles, including vitamins and nonprescription products, to a visit. This is sometimes called a "brown bag" review.
• Ask your pharmacist for a medication review. Many pharmacies in Canada and the US offer this service, and some plans cover it.
• Tell your clinician which pills are hardest to take, cost the most, or cause side effects.
• Share your priorities, such as staying alert, avoiding falls, or fewer pills.

Treatments that may no longer fit

Clinicians often look for these patterns during a review:

• A prescribing cascade: a new drug started to treat a side effect of another drug, when the first drug could be changed instead.
• Very tight blood sugar or blood pressure targets in frail older adults, which can cause dizziness, falls, or low blood sugar.
• Preventive medicines whose benefits take many years to appear, when your goals now focus on comfort and daily function.
• Two drugs from the same group, or a drug that was meant to be short term.

Questions to ask your clinician

• Why am I taking each of these medicines, and is the reason still present?
• Could any of my symptoms be side effects of my medicines?
• Which of my medicines are on lists of drugs that can be risky for older adults?
• Which one should we change first, and how slowly?
• What withdrawal or return of symptoms should I watch for?
• When will we check in after the change?

When to get care quickly

Call 911 or go to the emergency department if, after a change in medicines, you have chest pain, a seizure, severe shortness of breath, fainting, sudden confusion, or thoughts of harming yourself. For milder symptoms, call your clinician or pharmacist the same day.

Bottom line

More medicine is not always better. Deprescribing is a careful, shared process to keep the drugs that help you and remove those that no longer do. It works best with a full medicine list, one change at a time, a slow taper when needed, and close follow-up.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.