There is limited clinical evidence to guide deprescribing, but some broad principles can be applied (Fig. 1) 2,4,11,12

Prepare the patient for deprescribing
When starting a drug, explain to the patient that the outcome will be monitored and the drug might be ceased if there is no beneficial effect or a significant adverse effect occurs. Patient expectations can be discussed and managed at this time. This is particularly important for drugs which have Pharmaceutical Benefits Scheme (PBS) continuation criteria (for example cholinesterase inhibitors for Alzheimer's disease), as the clinician must confirm that there has been clinical improvement in order for PBS funding to continue. Prepare the patient for deprescribing
Recognise the need for deprescribing
The main clues that deprescribing might be useful are polypharmacy, adverse drug reactions (for example falls in older people), lack of efficacy and changes in treatment goals which may be secondary to the onset of terminal illness, dementia or frailty.
Prioritise medicines to cease or doses to reduce
A cautious approach is to stop or reduce the dose of one drug at a time. This helps to identify which drug might have been causing harm or, if withdrawal symptoms occur, to provide a guide for which drug to consider recommencing. If an adverse drug reaction is suspected, then the implicated drug should obviously be stopped first.
If the patient is elderly and taking multiple medicines then there are several possible approaches to identifying the drugs which are suitable for deprescribing, in particular focussing on anticholinergic and sedating drugs.2,13,14 Reducing the dose of a medicine or changing it from regular to 'as needed' might also be an appropriate goal.
Wean or taper the dose
In many cases, medicines can be ceased abruptly, while for others (beta blockers, benzodiazepines, corticosteroids, opioids, levodopa) sudden cessation can generate serious withdrawal and rebound syndromes. The duration of weaning can vary from days to months and is influenced by factors such as the drug's half-life, the availability of different dose form sizes and scored tablets, as well as the physiological and psychological responses of the patient. For psychotropic medicines, the overall aim might be to reduce the dose by 25% each month, adjusting this according to the patient's response.12,15,16 This is a reasonably conservative regimen that would be suitable for most other prescription drugs if there was concern about withdrawal or rebound. For patients who have taken benzodiazepines for a long time, there might also be a benefit in transferring the patient to an equivalent dose of diazepam, because of its long half-life, then commencing withdrawal. However, for patients who have had a serious adverse drug reaction, then usually the drug should be stopped immediately.
Monitor outcomes
If a significant withdrawal syndrome or rebound occurs, then the drug could be resumed. Withdrawal could be attempted later at a slower rate.
Assess patients for positive outcomes of deprescribing, such as decreased adverse effects and improved function. These benefits will be important for continuing compliance with deprescribing.