Drugs may sometimes be discontinued in older people with limited or no adverse effects.5 In other cases, the symptoms of the underlying condition may reappear or withdrawal effects may occur. A review did not find significant harms when antihypertensives, benzodiazepines and psychotropics were discontinued in older people.21
The risk of harm can be mitigated by gradually tapering medicines and carefully monitoring for withdrawal effects. It is often not possible to tell if a condition is a current problem while symptom-relieving drugs are used (e.g. proton pump inhibitors to manage reflux, or analgesics to manage pain). For these drugs, discontinuation should be trialled rather than considered definitive. If symptoms recur, restarting the medicine at a lower dose may be sufficient to manage this.21
Reappearance of the original disease or symptoms
Many older people are prescribed antihypertensives to reduce their risk of cardiovascular events. This needs to be carefully balanced with the potential for harms (e.g. dizziness, falls).22 A study of frail older people found that deprescribing antihypertensives resulted in an immediate increase in blood pressure, although this reverted to baseline within nine months.23 Another study found that systolic blood pressure increased by 7 mmHg (95% CI 3–12) after discontinuing antihypertensives.24 Blood pressure should be routinely monitored during the first year after deprescribing to identify increases that may occur.22
For symptom management, proton pump inhibitors are recommended for 2–8 weeks, yet they are commonly continued for prolonged periods.10 Stopping them may result in rebound hyperacidity, or lack of symptom control,10 especially during the first two weeks. A study that deprescribed proton pump inhibitors during hospital admissions found that 57% were still discontinued after three months.25 Tapering the dose may reduce the risk of rebound symptoms, particularly if the initial dose is high. Proton pump inhibitors, H2 antagonists or antacids (e.g. Mylanta) can be used as needed to relieve rebound symptoms.
The fracture risk in people with osteoporosis may be reduced using denosumab or bisphosphonates. Bisphosphonates can be discontinued after 3–6 years in many people without altering fracture risk.5,26 For example, a six-year study of zoledronic acid suggested treatment could be stopped after six annual infusions, with treatment effects maintained for at least three years.26 Unlike bisphosphonates, denosumab is not incorporated into the bone matrix so the effect on bone resorption is not maintained after treatment is discontinued. Discontinuing denosumab therefore results in rapid bone loss and the fracture risk reverts to baseline levels.27,28 Periodic monitoring may identify changes in bone mineral density after a bisphosphonate has been discontinued.
Withdrawal symptoms
Discontinuing drugs can result in withdrawal symptoms. People taking long-term benzodiazepines are likely to be physiologically dependent. A withdrawal syndrome can include anxiety, irritability, insomnia and myoclonic jerks. One study demonstrated that 38% of people reported withdrawal symptoms when discontinuing benzodiazepines and Z-drugs (zopiclone and zolpidem).29 This highlights the importance of slowly tapering medicines to minimise withdrawal symptoms.30 This also increases the likelihood of the medicine being successfully deprescribed.