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Researchers believe clinicians should have more support, but a prominent GP says numerous barriers make this a difficult proposition.
It is estimated around 400,000 people present to Australian emergency departments each year because of medication-related problems.
A new Monash University-led study has found that more than two thirds (71%) of clinical practice guidelines do not contain any advice on deprescribing.
The research, published in the British Medical Journal (BMJ), identified guidelines from Europe, North America, Australia, Asia and Africa published in the past 10 years and also revealed that
of the 80 that did contain deprescribing recommendations, most did not have detailed information on how to deprescribe.
Pharmacist Dr Aili Langford, who co-led the research, said the findings highlight a glaring omission in clinical practice guidelines internationally.
‘While deprescribing recommendations are becoming more common, which is encouraging to see, what stood out is the need for greater clarity and specificity in these recommendations,’ she said.
‘If recommendations are unclear, they are unlikely to be implemented as intended.
‘The potential benefits and harms of medicines can change over time as a person ages, acquires new medical conditions, takes new medicines and changes their care goals. Therefore, medicines should be regularly reviewed to make sure that they are still of benefit, and not causing harm.’
Despite the vast range in demographics and healthcare systems, insufficient deprescribing recommendations were found to be a universal trend.
Around 400,000 people present to Australian emergency departments each year because of medication-related problems, with the Pharmaceutical Society of Australia estimating at least 50% of this harm deemed preventable. The issue is further inflated for people living in aged care facilities, where more than 95% have at least one problem with their medicines detected at the time of a medicines review.
However, while RACGP Expert Committee – Quality Care member Dr Michael Tam agrees there is a relative gap in formalising deprescribing in treatment pathways, numerous barriers make this a difficult proposition.
‘There is simply less specific evidence pertaining to deprescribing, which can make formulating a clear evidence-based recommendation difficult,’ he told newsGP.
‘This results in the practical issue that there is simply a lot of contextual nuance to deprescribing, usually in the context of multimorbidity and polypharmacy, and this may not fit in well with what are disease-specific guidelines.
‘We need to be wary that poorly written or poorly considered guidance that overstates evidence, or under-recognises contextual factors in making a recommendation, might be worse than a guideline staying silent – within the overarching expectations that clinicians need to use their clinical judgement, including deprescribing when appropriate.’
So, while Dr Tam says it would be ‘excellent’ for clinical guidelines to include deprescribing information, he believes it needs to be a process that is properly resourced in development, rather than seen as an afterthought.
‘There is definitely a place for single-disease guidelines – they are useful in the way we as humans conceptualise and categorise disease and illness,’ he said.
‘However, we fundamentally live as an integrated whole-person, and not as a collection of diseases.
‘Guidelines that are overly prescriptive can end up being problematic, as what is best recommendation on average might not be the best recommendation for a specific person.’
Nonetheless, the study’s senior author and Chair of the Australian Deprescribing Network, Dr Emily Reeve, said the team is conducting ongoing research to support the development of actionable and evidence-based deprescribing recommendations.
‘While more comprehensive deprescribing recommendations may facilitate the implementation of deprescribing in practice, there remains a need for recommendations to be simple and digestible,’ she said.
‘Guideline language, for example, is integral – recommendations should be uncomplicated, clear and persuasive.
‘Although clinician expertise and discretion can be used to bridge the gap between recommendations and practice, in the absence of clear deprescribing recommendations, there is concern that recommendations will be misapplied, leading to unintended harm.’
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