This document provides an overview of de-prescribing. It begins with an introduction that defines de-prescribing and notes its importance in geriatrics and palliative care. It then outlines the seminar, reviewing literature on categories of patients and medications suitable for de-prescribing. Tools for de-prescribing like Beers criteria are presented, as well as a 5-step approach. Benefits include reducing burden and risks, while risks include withdrawal effects. The role of pharmacists in identifying unnecessary medications is described before concluding on the need for de-prescribing guidelines in Nigeria.

1. DE-PRESCRIBING – AN OVERVIEW
A Seminar presented by
NNAJI, AUGUSTINE CHUKWUKA
DEPARTMENT OF CLINICAL PHARMACY & BIOPHARMACY
SCHOOL OF POSTGRADUATE STUDIES
UNIVERSITY OF LAGOS
1

2. Outline
• Introduction
• Justification
• Objectives
• Literature review
• Pharmacist’s Role
• Conclusion
• References
2

3. Introduction
• De-prescribing: “is a systematic process supervised by a healthcare
professional that involves reviewing, tapering and withdrawing
inappropriate medications within the context of an individual patient’s
goals of care, level of functioning, life expectancy, values and
preferences. The overall goal is to improve patient outcome’’.
• Shared Decision Making
• Inappropriate polypharmacy
• Common in geriatrics and palliative care
• Also useful in other group of patients
(Scott et al., 2015; Ulley et al., 2019; Lee et al., 2021).
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4. Introduction (cont’d)
• Potentially Inappropriate Medicines (PIMs) use is considered one of the
commonly encountered medication-related problems among the older
population and in comorbidities.
• Other Medication-related problems (MRPs) includes:
- adverse drug reactions
- interactions and ineffectiveness
- improper drug selection and untreated conditions
- excessive or inadequate dosing
(Page et al., 2010; Lattanzio et al., 2012; Shah and Hajjar, 2012).
4

5. Introduction (cont’d)
• Prevalence of PIMs:
- Globally: Highly variable
- In Portugal: 46.1% of PIMs in 757 patients (Simoes et al., 2019).
- In South Africa: 29.6% of PIMs in 328 patients (Saka et al., 2019).
- In Saudi Arabia: 57.6% of PIMs in 4073 patients (Alhawassi et al., 2019).
• Prevalence of PIMs in Nigeria: Under-reported
- South West (Ibadan): 30.3% of PIMs in 220 patients (Fadare et al., 2015).
- South West (Ogun): 35.2% of PIMs 352 patients (Saka et al., 2019).
- North West (Kano): 29.9% of PIMs in 244 patients (Abubakar et al., 2021).
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6. Justification
• Polypharmacy among older adults is common and consequently older
patients are at higher risk of PIMs use.
• PIMs use increases the risk of hospitalization, drug-related problems
and other adverse health outcomes by two to three folds
• Maximizing patient benefit and minimizing harm can be achieved
through medication optimization reviews and de-prescribing
(Scott et al., 2015; Alhawassi et al., 2019).
6

7. Objectives
• To highlight categories of patients and medications to consider
for de-prescribing.
• To highlight some de-prescribing tools and steps
• To present the benefits and harms of de-prescribing
7

8. 8
Literature Review

9. Categories of patients for de-prescribing
No Risk group Comments
1 Polypharmacy Increases risk of ADRs
2 Multi-morbidity Higher chances of PIMs
3 Renal disease May require dose adjustment
4 Multiple prescribers and
transitions of care
Increased risk of duplication
(Steinman et al., 2014; Kua et al., 2019; Akande-Sholabi et al., 2020).
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10. Categories of patients for de-prescribing (cont’d)
No Risk group Comments
5 Limited life expectancy Changing goal of therapy
6 Poor adhering patients May be due to pill burden
7 Advanced age Predisposes to
polypharmacy
(Steinman et al., 2014; Kua et al., 2019; Akande-Sholabi et al., 2020).
10

11. Medication categories for de-prescribing
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Class Examples Reasons
1 Benzodiazepines
and
benzodiazepine
receptor agonists
Zolpidem,
Diazepam
Physical and psychological
dependence-,falls, impaired
cognition, reduced alertness,
2 Proton pump
inhibitors
Pantoprazole Fractures, Clostridium difficile
infections, vitamin B12 deficiency
and hypomagnesemia
3 Cholinesterase
inhibitors
Donepezil,
Galantamine
Dizziness, confusion, headache,
insomnia, agitation, weight loss
and falls.
(Park et al., 2017 ; Martin et al., 2018; Shrestha et al.,2020).

12. Medication categories for de-prescribing (cont’d)
Class Examples Reasons
4 Anti-diabetic
agents
Insulins, glyburide Hypoglycemia
5 Antipsychotics Haloperidol,
Risperidone,
Olanzapine
Metabolic disturbances,
drowsiness, injurious falls
6 Nonsteroidal anti-
inflammatory drugs
Ibuprofen, Diclofenac Increased risk of bleeding
(Park et al., 2017; Martin et al., 2018; Shrestha et al.,2020).
12

13. De-prescribing tools and criteria
13
Some de-prescribing criteria and guidelines
1. American Geriatrics Society Beers Criteria(AGS/Beers)
2. Screening Tool for Older Person’s Prescriptions (STOPP) criteria
3. Screening Tool to Alert Right Treatment (START) criteria
4. Improved prescribing in the elderly tool (IPET)/Canadian Criteria
5. Medication Appropriateness Index (MAI)
(Tosato et al., 2014; AGS/Beers, 2019; Fick et al, 2019).

14. 5-step approach to effective de-prescribing
Step 1:
Comprehensive
Medication History
Step 2: Identify
Potentially Inappropriate
Medications
Step 3: Determine if
medications can be
stopped and prioritize
Step 4:
Plan and initiate
withdrawal
Step 5: Monitoring,
support and
documentation
14
(Reeve et al., 2014; Scott et al., 2015; Lee et al., 2021).

15. Benefits of de-prescribing
15
• Helps to improve patient quality of life and overall health outcome
• Reduction in the burden of medication
• Reduction in the risk of falls
• Could help improve and/or preserve cognitive function
• Helps to reduce the risk of hospitalization and death
• Facilitation of improved adherence and reduction in economic burden
(Reeve et al., 2014; Potter et al., 2016; Garfinkel, 2018; Maust, et al., 2021).

16. Risks/harms of de-prescribing
They include:
• Adverse drug withdrawal syndrome
• Pharmacokinetic changes
• Pharmacodynamic changes
• Return of the medical condition.
(Reeve et al., 2015; Campins et al., 2017; Bloomfield et al., 2020).
16

17. Roles of the Pharmacist
• Pharmacists play key role in de-prescribing by identifying
unnecessary medications and working in collaboration with other
healthcare providers to implement changes to drug regimen that best
suits the patient
• Studies have shown that medication review by pharmacists led to
significantly lesser number of fall-risk medications and the number of
falls in the elderly
(Marvin et al., 2016).
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18. Conclusion
18
• De-prescribing can be framed as a part of good clinical practice.
• Shared decision making is critical for the success of de-prescribing
• Regular patient review is required for successful de-prescribing.
• Senior citizens and those with multi-morbidity may benefit more from de-
prescribing.
• In Nigeria, our healthcare team should collaborate towards establishing the
prevalence of PIMs and thus develop a de-prescribing framework for clinical
practice in Nigeria.

19. References
• Abubakar, U., Tangiisuran, B., Kolo, M., Yamma, A.I., Hammad M.A and
Sulaiman S.A.S. (2021) ‘Prevalence and predictors of potentially inappropriate
medication use among ambulatory older adults in Northern Nigeria’, Journal of Drugs
and Therapy Perspectives, 37(1), pp 94–99. Available at
https://link.springer.com/article/10.1007/s40267-020-00800-3
• Alhawassi, T.M., Alatawi, W. and Alwhaibi, M. (2019) ‘Prevalence of potentially
inappropriate medications use among older adults and risk factors using the 2015
American Geriatrics Society Beers criteria’ BMC Geriatrics 19(1), p154. Available at
https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1168-1
• Akande-Sholabi, W., Ajilore, O.C., Showande, S.J. and Adebusoye, L.A. (2020)
‘Potential inappropriate prescribing among ambulatory elderly patients in a geriatric
Centre in southwestern Nigeria: Beers criteria versus STOPP/START criteria’, Tropical
Journal of Pharmaceutical Research,19(5), pp 1105-1111 DOI: 10.4314/tjpr.v19i5.29
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20. References (cont’d)
• American Geriatrics Society Beers Criteria® Update Expert Panel
(AGS/Beers). (2019) ‘American Geriatrics Society 2019 Updated AGS Beers
Criteria® for Potentially Inappropriate Medication Use in Older Adults’, Journal
of American Geriatric Society, 67(4): 674-694.doi: 10.1111/jgs.15767.
• Bloomfield, H.E., Greer, N., Linsky, A.M., Bolduc, J., Naidl, T., Vardeny, O.,
MacDonald, R., McKenzie, L. and Wilt, T. J. (2020) ‘Deprescribing for
Community-Dwelling Older Adults: a Systematic Review and Meta-analysis’,
Journal of Gen Internal Medicine, 35(11), pp 3323-3332.
DOI: 10.1007/s11606-020-06089-2
• Campins, L., Serra-Prat, M., Gozalo, I., Lopez, D., Palomera, E., Agusti,
C. and Cabre, M. (2017) ‘Randomized controlled trial of an intervention to
improve drug appropriateness in community-dwelling polymedicated elderly
people’, Journal of Family Practice, 34(1), pp 36–42.
Doi.org/10.1093/fampra/cmw073
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21. References (cont’d)
• Duncan, P., Duerden, M. and Payne, R.A (2017) ‘Deprescribing: a
primary care perspective’, European Journal of Hospital Pharmacy,
24(1): 37–42. Doi:10.1136/ejhpharm-2016-000967
• Fadare, J.O., Desalu, O.O., Obimakinde, A.M., Adeoti, A.O., Agboola,
S.M. and Aina, F.O. (2015) ‘Prevalence of inappropriate medication
prescription in the elderly in Nigeria: A comparison of Beers and
STOPP criteria’, The International Journal of Risk Safety in Medicine,
27(4), pp 177-89. Doi: 10.3233/JRS-150660.
• Fick, D.M., Semla, T.P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R.,
DuBeau, C.E., Pezzullo, L., Epplin, J.J., Flanagan, N. (2019) ‘Updated AGS
Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’,
Journal of American Geriatrics Society, 67(4), pp 674-694. Doi:
10.1111/jgs.15767.
21

22. References (cont’d)
• Fick, D.M., Semla, T.P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R.,
DuBeau, C.E., Pezzullo, L., Epplin, J.J., Flanagan, N. (2019) ‘Updated AGS
Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults’,
Journal of American Geriatrics Society, 67(4), pp 674-694. Doi:
10.1111/jgs.15767.
• Garfinkel, D. (2018) ‘Poly-de-prescribing to treat polypharmacy’, Journal of
Therapeutic Advances in Drug Safety, 9(1), pp 25–43.
DOI: 10.1177/2042098617736192
• Kua, C. H., Mak, V.S.L. and Huey, L. S.W. (2019) ‘Health Outcomes of
Deprescribing Interventions Among Older Residents in Nursing Homes: A
Systematic Review and Meta-analysis’, Journal of American Medical Directors
Association, 20(3), pp 362-372. DOI: 10.1016/j.jamda.2018.10.026
22

23. References (cont’d)
• Lattanzio,F., Landi, F., Bustacchini, S., Abbatecola, A. M., Corica, F., Pranno, L.
and Corsonello, A. (2012) ‘Geriatric conditions and the risk of adverse drug
reactions in older adults: a review’, Drug Safety Journal, 35(1) pp 55–61.
Doi:10.1007/BF03319103
• Lee, J., Negm, A., Peters, R., Wong, E. K. C. and Holbrook, A. (2021)
‘Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-
related complications: a systematic review and meta-analysis’, British Medical
Journal, 11(2), pp e035978. DOI: 10.1136/bmjopen-2019-035978.
• Martin, P., Tamblyn, R., Benedetti, A., Ahmed, S. and Cara, T. (2018) ‘Effect of a
Pharmacist-Led Educational Intervention on Inappropriate Medication
Prescriptions in Older Adults: The D-prescribe Randomized Clinical Trial’,
The Journal of the American Medical Association, 320(18), pp 1889-1898.
DOI: 10.1001/jama.2018.16131
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24. References (cont’d)
• Marvin, V., Ward, E., Poots A.L., Heard, K., Rajagopalan, A. and Jubraj, B.
(2016) ‘Deprescribing medicines in the acute setting to reduce the risk of falls’,
European Journal of Hospital Pharmacy, 24(1), pp10-15.
http://dx.doi.org/10.1136/ejhpharm-2016-001003
• Maust, D.T., Strominger, J., Kim, H.M., Langa, K.M., Bynum S.C. (2021)
J.P.W., Chang, C., Kales, H.C., Zivin, K., Solway, E. and Marcus, ‘Prevalence
of Central Nervous System-Active Polypharmacy Among Older Adults With
Dementia in the US’, The Journal of the American Medical Association,
325(10), pp 952-961. DOI: 10.1001/jama.2021.1195.
• Page, R.L., Linnebur, S.A., Bryant, L.L. and Ruscin, J.M. (2010) ‘Inappropriate
prescribing in the hospitalized elderly patient: defining the problem, evaluation
tools, and possible solutions’, Clinical Interventions in Aging, 7(5), pp 75-87.
Doi: 10.2147/cia.s9564.
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25. References (cont’d)
• Park, H.Y., Park, J.W., Song, H.J., Sohn, H. S. and Kwon, J. (2017) ‘The
association between polypharmacy and dementia: a nested case-control
study based on a 12-year longitudinal cohort database in South Korea’,
PLoS One Journal, 12(1), p e0169463. Doi:10.1371/journal.pone.0169463.
• Potter, K., Page, A., Clifford, R. and Etherton-Beer, C. (2016)
‘Deprescribing: a guide for medication reviews’, Journal of Pharmacy
Practice and Research,46(4), pp 358-367. Doi.org/10.1002/jppr.1298
• Reeve, E., Shakib,S., Hendrix, I., Roberts, M.S., Wiese, M.D. (2014)
‘Review of deprescribing processes and development of an evidence-
based, patient-centred deprescribing process’, British Journal of Clinical
Pharmacology, 78(4), pp 738-747 https://doi.org/10.1111/bcp.12386
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26. References (cont’d)
• Reeve, E., Gnjidic D., Long J. and Hilmer, S. (2015) ‘A systematic review
of the emerging definition of 'deprescribing' with network analysis:
implications for future research and clinical practice’. British Journal of
Clinical Pharmacology, 80(6), pp 1254-68. DOI: 10.1111/bcp.12732.
• Shah, B. M. and Hajjar, E. R. (2012) ‘Polypharmacy, adverse drug
reactions, and geriatric syndromes’, Journal of Clinical Geriatric
Medicine, 28, 173–186. Doi:10.1016/j.cger.2012.01.00
• Saka, S. A., Oosthuizen, F. and Nlooto, M. (2019) ‘Potential
inappropriate prescribing and associated factors among older persons in
Nigeria and South Africa’, International Journal of Clinical
Pharmacy, 41(1), pp 207–214. Available at
https://link.springer.com/article/10.1007/s11096-018-0770-1 26

27. References (cont’d)
• Shrestha, S., Poudel, A., Steadman, K. and Nissen, L. (2020) ‘Outcomes of
deprescribing interventions in older patients with life-limiting illness and limited
life expectancy: A systematic review’, British Journal of Clinical Pharmacology,
86(10), pp1931-1945. Doi: 10.1111/bcp.14113.
• Scott, I. A., Hilmer, S.N., Reeve, E., Potter, K., Couteur, D.L., Rigby, D.,
Gnjidic D., Mar, C.B.D., Roughead, E.E., Page, A., Jansen, J. and Martin J.H.
(2015) ‘Reducing inappropriate polypharmacy: the process of deprescribing’,
The Journal of the American Medical Association, 175(5), pp 827-834.
Doi:10.1001/jamainuternmed.2015.0324.
• Simoes, P.A.S., Santiago,L.M., Maurício, K. and Simoes, J.A. (2019)
‘Prevalence Of Potentially Inappropriate Medication In The Older Adult
Population Within Primary Care In Portugal: A Nationwide Cross-Sectional
Study’, Journal of Patient Preference Adherence,13(1): pp1569–1576.
doi:10.2147/PPA.S219346
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28. References (cont’d)
• Steinman, M.A., Miao, Y., Boscardin,W.J., Komaiko, K.D.R., Schwartz, J.B.
(2014) ‘Prescribing quality in older veterans: a multifocal approach’. Journal of
General Internal Medicine, 29 (10), pp 1379-86.. Doi: 10.1007/s11606-014-
2924-8
• Tosato, M., Landi, F., Martone, A.M., Cherubini, A., Corsonello, A., Volpato, S.,
Bernabei, R., Onder, G. (2014) ‘Potentially inappropriate drug use among
hospitalized older adults: Results from the CRIME study’, Age and Ageing
Journal, 43(6), pp 767-73. Doi: 10.1093/ageing/afu029.
• Ulley, J., Harrop, D., Ali, A., Alton., S. and Davis, S. F. (2019)
‘Deprescribing interventions and their impact on medication adherence in
community-dwelling older adults with polypharmacy: a systematic review’,
BMC Geriatrics, 19(1), p 15. DOI: 10.1186/s12877-019-1031-4.
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