Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice

The recent article by Wallis and colleagues "Swimming Against the Tide: Primary Care Physicians' Views on Deprescribing in Everyday Practice" raises important concerns surrounding the feasibility of implementing deprescribing into routine clinical practice. Physicians felt that deprescribing could damage relationships with patients and families due to patient expectations to be prescribed medications rather than taken off them when they have a problem. This is exacerbated by guidelines aimed at starting drugs in single disease states, with little guidance on how to take drugs away. Physicians also reported a lack of time and resources to implement deprescribing into their practices. These findings confirm what has previously been demonstrated in the literature surrounding prescriber barriers to deprescribing [1]. We would like to address a few of the findings reported by Wallis et al.

Physicians have stated that they expect patients will view deprescribing as negative or that patients will feel given up on [2], which was confirmed in the present article. However, many patients have reported being willing to consider deprescribing for various medication classes (e.g. proton pump inhibitors, statins, benzodiazepines)[3-5]. Some patients will appreciate the opportunity to discuss and trial medication discontinuation or dose reduction (reducing doses can be beneficial for older patients when high doses are causing adverse effects or not providing additional benefit). Therefore, we offer that it is important to clarify what patient goals and expectations are surrounding treatment and allow this to guide decisions on continuation of medications versus deprescribing [6,7]. While it is true that some patients may not want to pursue deprescribing, evidence suggests that many will. We should not make the assumption that patients will view deprescribing negatively and therefore not present the choice to them at all. Where deprescribing is an option for a patient, the choice should be offered (i.e. continuation versus deprescribing), patient goals and preferences should be identified, the benefits and harms of different options should be presented, and a tailored and shared choice should be made between the patient and clinician [8].

We would also like to address the perception that there is a lack of time and resources to pursue deprescribing in practice. Limited time during appointments with primary care physicians is certainly an impediment to deprescribing. However, we feel that using an interdisciplinary approach to deprescribing can help to improve efficiency and also foster collaboration. For example, pharmacists can take on a large role in facilitating deprescribing. As drug therapy experts collaborating with physicians, pharmacists can take time to educate patients, develop deprescribing care plans and monitor and follow-up on deprescribing interventions. Other members of the healthcare team (e.g. social workers, physiotherapists) can also be part of deprescribing interventions by offering non-pharmacological alternatives to medications and by assisting with follow-up and monitoring. A team-based approach can help to address the perception that there is a lack of time and priority for deprescribing.

Several deprescribing resources are now available to assist physicians with deprescribing. These resources address the perception that there is a lack of information available to guide deprescribing. Websites such as medstopper.com and deprescribing.org have been created to provide clinicians with the tools and resources needed to deprescribe in clinical practice. For example, deprescribing.org contains decision support tools and patient information pamphlets which can be used to guide the deprescribing process. Our research group has also developed evidence- based deprescribing guidelines, which will be freely available through Canadian Family Physician and will provide detailed guidance to clinicians on deprescribing specific medication classes [9]. Development of other deprescribing guidelines is also underway [10]. Therefore, progress is being made to address the perception that there is a lack of information available to guide deprescribing.

In summary, we agree that deprescribing can be a difficult undertaking in a busy primary care environment. However, resources are available to assist with the deprescribing and other healthcare team members can collaborate to enhance the process. Deprescribing may align well with patient goals and values in many cases; therefore, we should not assume patients will view deprescribing as negative. The choice to continue a medication or try deprescribing should be offered to patients where relevant. This decision should be carefully discussed with patients to arrive at a shared decision that is consistent with patient values and preferences.

References 1. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4(12):e006544. doi:10.1136/bmjopen-2014-006544.
2. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793-807. doi:10.1007/s40266-013-0106-8.
3. King MB, Gabe J, Williams P, Rodrigo EK. Long term use of benzodiazepines: the views of patients. Br J Gen Pract. 1990;40(334):194- 196. http://www.ncbi.nlm.nih.gov/pubmed/1973049.
4. Thompson W, Black C, Welch V, Farrell B, Bjerre LM, Tugwell P. Patient Values and Preferences Surrounding Proton Pump Inhibitor Use: A Scoping Review. Patient - Patient-Centered Outcomes Res. June 2017. doi:10.1007/s40271-017-0258-4.
5. Tjia J, Kutner JS, Ritchie CS, et al. Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness. J Palliat Med. May 2017. doi:10.1089/jpm.2016.0489.
6. Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. Bmj. 2016;2893(June):i2893. doi:10.1136/bmj.i2893.
7. Thompson W, Farrell B, Welch V, Tugwell P, Bjerre L. Should I continue taking my acid reflux medication? Design of a pilot before/after study evaluating a patient decision aid. Can Pharm J. 2017;150(1):19-21.
8. Lehman R, Tejani AM, McCormack J, Perry T, Yudkin JS. Ten Commandments for patient-centred treatment. Br J Gen Pract. 2015;65(639):532-533. doi:10.3399/bjgp15X687001.
9. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354-364. http://www.ncbi.nlm.nih.gov/pubmed/28500192.
10. Reeve E. Evidence-Based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine in People with Dementia. https://www.clinicalguidelines.gov.au/register/evidence-based-clinical- practice-guideline-deprescribing-cholinesterase-inhibitors-and. Published 2017.

Competing interests: None declared