Letter to the Editor
Editor, – The authors of the article on deprescribing (Aust Prescr 2011;34:182-5) remind us about the critical role all clinicians play in generating, and potentially mitigating, polypharmacy. There is a paucity of high quality evidence to guide when to discontinue medications, especially where the event to be avoided may not be experienced for years or decades.
Initiating any medication requires a framework to evaluate its continuing use and includes:
- explicitly categorising the level of prevention (primary, secondary or tertiary) that the new medication is addressing
- agreed, measurable and clinically relevant endpoints
- the time by which clinical benefits are likely to be experienced
- the time frame for expected toxicities
- the time period in which it is likely that a condition will manifest after a medication is stopped
- a plan to individually balance the net clinical benefit (observed clinical benefits vs harms).1,2
As a patient’s overall clinical condition, prognosis and range of comorbid illnesses shift over time, their individual benefit:harm ratio will need to be updated continually for each long-term medication. Individually, the number needed to treat and the number needed to harm are not static nor linear over time, and the ratio between them will shift from the time each medication is introduced.3
With so much effort expended by industry establishing the short-term efficacy of medications that will be used in the long term, it is time for an expansion of comparative effectiveness research defining when long-term medications can be ceased safely and in which sub-populations this should occur.4,5 To minimise iatrogenic morbidity and premature mortality, publicly funded studies to develop credible evidence are needed urgently to inform timely and confident discontinuation of appropriate medications.
David C Currow
Palliative and Supportive Services
Flinders University, Adelaide
Jean S Kutner
Division of General Internal Medicine
University of Colorado, USA
Amy P Abernethy
Duke Cancer Institute
Duke University Medical Center
North Carolina, USA
- Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ 2004;329:909-12.
- Quill TE, Holloway R. Time-limited trials near the end of life. J Am Med Assoc 2011;306:1483-4.
- Currow DC, Abernethy AP. Frameworks for approaching prescribing at the end of life. Arch Intern Med 2006;166:2404.
- Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med 2010;170:1648-54.
- Abernethy AP, Aziz NM, Basch E, Bull J, Cleeland CS, Currow DC, et al. A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group. J Palliat Med 2010;13:1407-13.
- Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med 2012;28:237-53.
- Abernethy AP, Currow DC. Time-limited trials. J Am Med Assoc 2012;307:33-4.