Reducing or discontinuing the use of drugs that are not helping the patient, or are even having a negative effect, is a way to "do no harm". This concern is far from new, as evidenced by this quote (our translation) from the 18th century French psychiatrist Philippe Pinel: "(…) in diseases of the mind, as in many other illnesses, there is an art to administering medicines properly, but there is an even greater art to knowing when to do without". The term "deprescribing" has been used more and more in recent years. But deprescribing is not easy.

There are some situations in which prescribing a drug is not advisable. This applies when the drug exposes the patient to risks that far outweigh its very minor or highly uncertain foreseeable benefits. It certainly applies to Prescrire's "Drugs to avoid", a list of drugs that are more dangerous than beneficial, which we have been updating annually for the past 10 years (see "Towards better patient care: drugs to avoid in 2022" > HERE). Healthcare professionals serve patients' interests by not prescribing these drugs in the first place. Or by helping patients to discontinue these drugs, even if met with resistance from patients who see nothing wrong for the time being with taking these treatments, and from prescribers who do not perceive the risks.

Many other drugs have a positive harm-benefit balance when taken for a short period of time but, in the long term, can provoke adverse effects that are disproportionate to any benefit patients can hope to obtain. The dearth of robust evaluation data available to guide the deprescribing process in these situations is striking. A few salient facts can help healthcare professionals carefully prepare to support patients through the process of discontinuing a long-term treatment: see for example "Tramadol: achieving successful withdrawal after prolonged use" > HERE, or "Difficulties encountered on discontinuing topical corticosteroids" (Prescrire Int n° 230 > Pdf, subscribers only) and "Stopping antidepressant therapy: plan tapered withdrawal"  > HERE.

Deprescribing, like prescribing, is not without risk. The process is similar: it requires evaluating, for and with each patient, the likelihood that they will benefit from stopping the treatment and the chances that stopping it will harm them, then weighing these probabilities against the probabilities of benefit and harm associated with continuing the treatment. Sometimes the conclusion will be not to deprescribe, or to wait for a more favourable time: see "Pragmatism" (Prescrire Int n° 235 > Pdf, subscribers only).

When a drug is first being prescribed, it is useful to tell the patient the reason for the treatment and its duration, which often leads to a discussion on the value of deprescribing and how this will happen when the time comes.

©Prescrire 1 March 2022

Source: "Rational deprescribing" Prescrire International 2022; 31 (235): 59. Free

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