De Prescribing

Version 2.
0 September 2017
Deprescribing: A Practical
Guide
The information in this booklet should be used as a pragmatic decision aid, in
conjunction with other relevant patient specific data.
Useful resource links

http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/clinical_guidelines_fr
ont_page/PrescQipp_IMPACT.pdf
https://www.nice.org.uk/guidance/ng56/resources
With acknowledgement to NHS Highland, NHS Coventry, NHS Cumbria, North Derbyshire,
NHS Warwickshire CCGs and PrescQIPP
Developed by the NHS Southern Derbyshire CCG Medicines Management Team.

For NHS use only. Not to be used or reproduced without express permission from the
Medicines Management Team.
Original authors: Vicki Starkey & Temi Omorinoye Medicines Management Pharmacist
Updated by: Debbie Railton, Shabnum Aslam, Nigel Jones, Tom Goodwin, Medicines Management
Pharmacists
Document updates Date update

All four CCG logos added to the front cover September 2017
Link to NICE resource tool and IMPACT tool added to
front cover
Definition added
Possible barriers added
Links to use deprescribing algorithms updated
Further Training Resources added
Page 1 of 14
First produced: October 2013
Updated: September 2017
Review date: August 2019
Version 2.0 September 2017
CONTENTS
Page
Definition 3
Key Points 3
How to deliver 3
Possible barriers 4
Identification of patients who may benefit 6
Identifying frailty 6
End of Life 7
Risk vs benefits of medication 7
Approach to reviewing medicines 7
Aide Memoire of things to consider before initiating a new medicine 8
or continuing prescribing
Useful deprescribing algorithms 10
References 10
Further Training resources 11
Top medicines to consider ‘trial without’ 13
Page 2 of 14
Deprescribing: A Practical Guide
September 2017
Definition
Deprescribing is synergistic with inappropriate polypharmacy and is the process of tapering,

withdrawing, discontinuing or stopping medicines to reduce potentially problematic
polypharmacy, adverse drug effects and inappropriate or ineffective medicine use by
regularly re-evaluating the ongoing reasons for, and effectiveness of medication therapy.
This should be done in partnership with the patient (and sometimes their carer) and
supervised by a healthcare professional.
Aims of deprescribing
 Improve quality of life

 Avoid worsening of disease or causing withdrawal effects
 Be effective in reducing pill burden
Key Points
 Discuss deprescribing before initiating any new medicines for a trial period.
 It is essential to deprescribe, reduce or substitute inappropriate medicines.
 Deprescribing should be planned, one medicine at a time, offered as a trial, the dose
gradually tapered and any returning symptoms monitored.
 Deprescribing should be performed as a partnership between the patient and the
prescriber.
 Regular patient review, with support from a healthcare professional is required for
successful deprescribing.
 It is sometimes better not to start a medicine than to tackle deprescribing in the future,
particularly in certain therapeutic areas.
 Older people, those who are end of life and those with increasing frailty are frequently
prescribed unnecessary or higher risk medicines and should have more frequent
medication reviews.
How to deliver
Steps to stopping a medication
A five step process can be used when stopping medicines; this should be initially as a trial:
1. Gain a comprehensive medication history and check adherence, if a medicine is rarely or

never taken this makes stopping easy (e.g. patient states in the consultation they are not
taking a particular medicine or if the medicine is administered the patient may continually
spit out doses without swallowing).
2. Identify any potentially inappropriate polypharmacy (PIP).
3. Determine whether the PIP can be stopped.
4. Plan the withdrawal regimen: reduce or stop one medicine at a time, if problems develop
it makes it easier to identify the likely cause.
Page 3 of 14
Consider if the medicine can be stopped abruptly, e.g. if toxicity has developed, or needs
to be tapered, this is usually the best option; sometimes a smaller dose may need to be
continued long term.
5. Check for benefit or harm after each medicine has been reduced or stopped (provide
contact details to the patient for support in case of problems), this may include monitoring
tests.
However, there are different approaches to stopping medicines that may be emploued:
 Stepwise’ approach
Useful if the patient is well and clinically stable but there is a risk that multiple changes in
drugs will destabilise their situation. Tapering the dose helps reduce the likelihood of an
adverse withdrawal event for some medicines.
 All at once’
Useful if the patient is unwell as a result of likely drug side effects or in a safe monitored
environment (e.g. admission to hospital).
 Mixed’ approach
In practice, often several drugs can be stopped or reduced at once with little chance of harm.
However, certain drugs (e.g. antidepressant and antipsychotic drugs) will need to be
withdrawn more cautiously. In these situations it should be documented clearly which drugs
can be stopped immediately and which drugs are to be withdrawn more cautiously.
Possible barriers
Deprescribing must be done judiciously, with monitoring, to avoid worsening of disease or

causing withdrawal effects. This needs careful discussion on an individual basis to gain
patient understanding and acceptance. It may be helpful to use different terminology for
patients. Treatment and care should take into account individual needs and preferences.
People who use health and social care services should have the opportunity to make
informed decisions about their care and treatment, in partnership with their healthcare
professionals and social care practitioners. It is recognised this is a complex process, not a
single act, involving multiple steps.
 Breach of duty
A healthcare professional is open to a claim of clinical negligence if their actions fall
below the reasonable standard of their peers. To succeed in a claim of clinical
negligence, a claimant must establish all of the following elements:
 A duty of care – A healthcare professional has a clear duty of care to patients under their
care.
AND
 Breach of duty – It must be shown that the claimant did not receive the appropriate
standard of reasonable care.
Page 4 of 14
This is established where it can be shown that no other reasonable practitioner of like
expertise, skill and experience, faced with the same set of circumstances would have
acted likewise.
AND
 Harm was caused
AND
 Causation arises where it can be shown that but for the negligence act or omission, the
outcome would have been different i.e. the breach in duty caused the adverse outcome
which arose. This link can be difficult to prove.
 Communication/ Shared decision making

Patients have a right to be involved in discussions and make informed decisions about
their care. The person’s needs and preferences must be considered. The treatment, care
and if appropriate the deprescribing process should all be explained in a way the person
understands. Suggested definition of deprescribing for patients would involve the words:
Helping you to take the right medicines for you’.
To avoid misunderstanding, suggest a ‘trial without’ rather than just stopping medicines.
Patient decision aids (PDA’s) are of value for the shared decision making process. These
are appropriate when more than one course of action is possible and where the best
decision depends on the patient’s reaction to the outcome probabilities. Short versions that
can be used in a consultation include PDAs developed by NICE as part of a clinical guideline
intended to help a person making a decision weigh up the possible advantages and
disadvantages of the different treatment options (which may include no treatment) – see
Useful deprescribing algorithms section.
Clinical documentation
Good clinical documentation is essential when deprescribing. There should be a clear record
of the logical reasons behind the changes being made, particularly where the care decision
does not match what the best available evidence seems to suggest.
Lack of consent
Consent of the individual must be sought and where applicable then a mental capacity
assessment completed if appropriate. To be valid consent requires three essential
components – it must be free, full and informed - i.e. a patient must have capacity to make
the decision in full knowledge of all relevant information and must do so voluntarily.
Time
Enough time is needed to discuss care. This may result in longer or alternative forms of
consultation, and regular, planned reviews may be of benefit.
Page 5 of 14
As deprescribing becomes accepted practice practitioners who fail to consider deprescribing

and advise patients of the potential benefits and options may expose themselves to clinical
negligence claims. Patient consent to stop, start, change or reduce a medicine must be
based on full disclosure of all material risks to that patient. When deprescribing is
undertaken in partnership with patients, supported by the knowledge, skills and experience
of both patient and clinicians and the patient’s values and preferences based on clinical skill,
judgement and evidence based medicine, the law presents no barriers to deprescribing.
Identification of patients who may benefit
It is important to consider patient groups that are likely to be taking many medicines and are
particularly vulnerable to adverse drug reactions. These include:
 Multi-morbidity patients- presence of two or more long-term health conditions

 Polypharmacy- patients taking large numbers of medicines (>15)
 Elderly (>75yr) frail patients
 Housebound patients
 Patients with indications of shortened life expectancy/ end of life
 Vulnerable patients
 Decline in hepatic function / renal function
Identifying frailty
Adults who have frailty are at particular risk of adverse drug reactions, drug to drug
interactions and rapid deterioration if necessary medication is not optimised (e.g. for
treatment of heart failure). Frailty assessment must be considered in people with
multimorbidity.
Various tools exist to identify and assess frailty. The Gold Standards Framework defines
frailty as:
 Individuals who present with multiple co morbidities with significant impairment in day to
day living and:
 Deteriorating functional score e.g. performance status
 Combination of at least three of the following symptoms:
Weakness
Slow walking speed
Significant weight loss
Exhaustion
Low physical activity
Depression
In patients with frailty deprescribing must be considered to reduce any inappropriate

polypharmacy, monitoring renal function and hepatic function carefully and adjusting doses
to prevent toxic accumulation of drugs.
Page 6 of 14
End of Life
The palliative approach should be considered the last phase for patients with multi-morbidity
in whom multiple active treatments are no longer appropriate one percent of patients on an
average GP list will be coming towards the end of their life. When deprescribing in this group
of patients consider the surprise question:
“Would you be surprised if this person died in the next year?”
 If ‘No’ then for any new medicine additional considerations are needed
 It may not be appropriate to start some medicines or to continue others.
Open and transparent discussions must be had with patient, relatives and carers and the
following questions should be considered where appropriate:
 Who is taking responsibility for the medicines?

 What are the medicines achieving?
 The harm to benefit profile should be considered.
Risk vs Benefits of Medication
When deprescribing it is important to discuss benefit to harm profile with the patient using
patient decision aids. The ‘number needed to treat (NNT)’ is a measure of how effective a
particular medication is. The NNT is the average number of patients who are needed to be
treated for one benefit to be realised compared with a control in a clinical trial. (defined as
the inverse of relative risk reduction). So if treatment with a medicine for one year reduces
the death rate over five years from 5% to 1%, the absolute risk reduction would be 4% (5
minus1) and the NNT would be 100/4 = 25. That means the number needed to treat with that
medicine for one year to prevent one death is 25. The ideal NNT is 1, where everyone
improves with treatment. The higher the NNT, the less effective the treatment.
The NICE database of treatment effects (NG56) is a useful interactive resource for
prescribers to make decisions regarding which treatments are of benefit to the patient. This
tool is designed to inform discussions between patient and clinician when considering the
benefits and harms of taking long term medication as it shows basic data from clinical trials
covering annualised absolute effect and numbers needed to treat.
https://www.nice.org.uk/guidance/ng56/resources
Approach to reviewing medicines
A number of screening tools are in use for carrying out medication reviews. Clinicians should
use the tool they find the easiest to use to support the medication review process. The care
should then be tailored to each individual patient’s needs. Example of tools of use:
IMPACT tool: Improving Medicines and Polypharmacy Appropriateness Clinical Tool
STOP/START tool: identifies high risk problems in prescribing for older people, both in terms
of reducing medicine burden and adding in potentially beneficial therapy.
NO TEARS: Need and indication, Open questions, Tests and monitoring, Evidence and
guidelines, Adverse events, Risk reduction or prevention, Simplification and switches.
Page 7 of 14
7-steps approach: Polypharmacy guidance centres around the individual patient.
Beers Criteria: Medicines that can cause increased adverse events in older people because
of altered pharmacokinetics, co-morbidities or physiological changes associated with aging.
It is also important, when optimising treatment to consider non-pharmacological treatments

that may be started as well as stopped.
Aide Memoire of things to consider before initiating a new medicine or continuing

prescribing
1. Disease
Are the symptoms caused by a disease or due to a medicine already being taken? (Have all
medicines been taken correctly?)
Consider the time to benefit, have you asked yourself the ‘surprise question’? Is the patient
moving towards end of life?
Has physiology changed significantly? Will this affect the metabolism of the proposed
medicine?
2. Medicine
Is there a documented indication for the medicine about to be prescribed?
Is the medicine effective for the condition? Is there sufficient evidence? Does the medicine
produce limited benefits for the indication?
Are there any clinically significant drug interactions? Have these been explained to the
patient?
Is there unnecessary duplication with other medicines?
Is the likely duration of therapy known and acceptable to both doctor and patient?
Is the use of the medicine consistent with current guidelines?
Does the dose need to be titrated? If so by who and how? Is the patient aware?
3. Patient
Will the patient take/ use the medicine? What are the likely adverse effects?
Is the dose and frequency correct? Is the frequency practical for the patient?
Do they feel they have an acceptable medication burden?
Will the patient comply with any monitoring? Will the new medicine excessively add to the
medication burden?
What is the clinical and personal significance of this specific medicine for this particular
patient?
Page 8 of 14
How will the patient know the medicine is working?
When will you follow up and who should the patient contact is any problems arise?
Does the patient understand the expected outcomes and what will happen if they are not
reached or reduce over time? Has deprescribing been discussed before initiating a new
medicine?
Is the patient (and /or their family or carer) aware of stopping criteria and any alternatives
following this treatment- are they at the end of a pathway?
4. Adherence
Have you explained how long it will take for the medicine to start working? Any potential
side-effects?
Could the community pharmacist provide support using a New Medicine Service or
Medicines Use Review?
Would a medication passport help?
5. Choice
Have you had an open and honest discussion about the advantages and disadvantages of
the medicine?
Have you considered using a patient decision aid or tool to support and help the patient
understand the NNT, NNH and probability of the risk and benefits of the proposed
treatment?
Have you considered non-pharmacological options?
Does the patient need more time to consider the options fully? Do they need to discuss with
their family or do they need more information? Is another consultation needed?
6. Cost
Is this medicine the least expensive compared with others of equal effectiveness?
Page 9 of 14
Useful deprescribing algorithms
https://www.prescqipp.info/resources/send/356-polypharmacy-practical-guide-to-
deprescribing/3415-attachment-2-proton-pump-inhibitor-desprescribing-algorithm
deprescribing/3416-attachment-3-noac-and-lmwh-deprescribing-algorithm
deprescribing/3417-attachment-4-bisphosphonates-for-osteoporosis-secondary-
prevention-deprescribing-algorithm.
References
(1) Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing processes and

development of an evidence-based, patient-centred deprescribing process. Br J Clin
Pharmacol 2014; 78:738-47.
(2) Thomas K et al. the Gold Standards Framework Centre in End of Life Care CIC.
Prognostic Indicator Guidance (PIG) 4th edition. The Royal college of General
Practitioners. October 2011.
(3) Duerden M, Avery T, Payne R et al. Polypharmacy and medicines optimisation: making
it safe and sound. Kings Fund Report 2013.
(4) Shared decision making; NHS Right Care. The BMJ Group.2012.
(5) PRESQIPP resources, Modules 1-6 Polypharmacy and Deprescribing. 2017.
(6) NICE Medicines Optimisation NG5. The safe and effective use of medicines to enable
the best possible outcome. https://www.nice.org.uk/guidance/ng5.
(7) Mental Capacity Act 2005 http://www.legislation.gov.uk/ukpga/2005/9/contents
(8) Kelly O, Barnett N. Deprescribing- Is the law on your side? European Journal of
Hospital Pharmacy, Vol 24, Issue 1.
(9) NICE Multimorbidity: Clinical assessment and management. Database of treatment
effects NG56. https://www.nice.org.uk/guidance/ng56/resources.
(10) NICE. Patient decision aid. Statins to reduce the risk of CHD and stroke: patient
decision aid. 2014
(11) https://www.prescqipp.info/resources/send/356-polypharmacy-practical-guide-to-
deprescribing/3415-attachment-2-proton-pump-inhibitor-desprescribing-algorithm
deprescribing/3416-attachment-3-noac-and-lmwh-deprescribing-algorithm
deprescribing/3417-attachment-4-bisphosphonates-for-osteoporosis-secondary-
prevention-deprescribing-algorithm.
Page 10 of 14
Further Training
Accessing the Deprescribing Programme Modules On-Line
Step 1
Access PrescQIPP website- https://www.prescqipp.info/

If not already registered then register, if registered continue to Step 3
Complete the fields below
(The full access passphrase is ‘nightjar’)
Page 11 of 14
Step 3
Login to PrescQIPP
Click on the “learn” tab on top tool bar and select the polypharmacy and
deprescribing option on the far right hand side the screen.
Once selected you may enrol onto the deprescribing programme.
Page 12 of 14
Page 13 of 14
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Version 2.

Useful resource links

Developed by the NHS Southern Derbyshire CCG Medicines Management Team.

Document updates Date update

Identification of patients who may benefit 6

Risk vs benefits of medication 7

Approach to reviewing medicines 7

Aide Memoire of things to consider before initiating a new medicine 8

Useful deprescribing algorithms 10

Further Training resources 11

Top medicines to consider ‘trial without’ 13

Deprescribing: A Practical Guide

Deprescribing is synergistic with inappropriate polypharmacy and is the process of tapering,

 Improve quality of life

Steps to stopping a medication

1. Gain a comprehensive medication history and check adherence, if a medicine is rarely or

Deprescribing must be done judiciously, with monitoring, to avoid worsening of disease or

 Harm was caused

 Communication/ Shared decision making

Helping you to take the right medicines for you’.

As deprescribing becomes accepted practice practitioners who fail to consider deprescribing

Identification of patients who may benefit

 Multi-morbidity patients- presence of two or more long-term health conditions

In patients with frailty deprescribing must be considered to reduce any inappropriate

“Would you be surprised if this person died in the next year?”

 Who is taking responsibility for the medicines?

Risk vs Benefits of Medication

Approach to reviewing medicines

IMPACT tool: Improving Medicines and Polypharmacy Appropriateness Clinical Tool

7-steps approach: Polypharmacy guidance centres around the individual patient.

It is also important, when optimising treatment to consider non-pharmacological treatments

Aide Memoire of things to consider before initiating a new medicine or continuing

Is there a documented indication for the medicine about to be prescribed?

Is there unnecessary duplication with other medicines?

Is the use of the medicine consistent with current guidelines?

Do they feel they have an acceptable medication burden?

How will the patient know the medicine is working?

Would a medication passport help?

Have you considered non-pharmacological options?

Useful deprescribing algorithms

(1) Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing processes and

Accessing the Deprescribing Programme Modules On-Line

Access PrescQIPP website- https://www.prescqipp.info/

Complete the fields below

(The full access passphrase is ‘nightjar’)

Once selected you may enrol onto the deprescribing programme.

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