The Art of De-prescribing in Internal Medicine: A Comprehensive Review for Critical Care Practitioners

Dr Neeraj Manikath ,claude.ai

Abstract

Background: Polypharmacy has emerged as a significant challenge in contemporary internal medicine, particularly affecting elderly patients and those with multiple comorbidities. De-prescribing, the systematic process of identifying and discontinuing medications where potential harms outweigh benefits, represents a paradigm shift from the traditional "start early, continue indefinitely" approach.

Objective: To provide critical care practitioners with evidence-based strategies, practical tools, and clinical pearls for implementing effective de-prescribing practices in internal medicine settings.

Methods: This narrative review synthesizes current literature on de-prescribing methodologies, polypharmacy management, and validated assessment tools including STOPP/START criteria.

Results: De-prescribing interventions demonstrate significant potential for reducing adverse drug events, healthcare costs, and improving quality of life in complex medical patients. Implementation requires structured approaches, interdisciplinary collaboration, and careful patient selection.

Conclusion: Mastering the art of de-prescribing is essential for modern internal medicine practitioners to optimize patient outcomes while minimizing medication-related harm.

Keywords: De-prescribing, polypharmacy, elderly, STOPP/START criteria, medication optimization, internal medicine

Introduction

The landscape of internal medicine has witnessed a dramatic evolution in prescribing practices over the past three decades. The contemporary hospitalized patient averages 8-12 medications during their stay, with elderly patients often discharged on 15 or more medications¹. This pharmacological complexity, termed polypharmacy, has transformed from an occasional clinical challenge to a ubiquitous reality in modern practice.

De-prescribing, defined as "the planned and supervised process of dose reduction or stopping of medication that might be causing harm or no longer providing benefit," represents a fundamental shift in therapeutic philosophy². Unlike medication discontinuation driven by adverse events, de-prescribing is a proactive, systematic approach that requires clinical expertise, patient engagement, and careful monitoring.

🔑 Pearl: The goal of de-prescribing is not to minimize medication count but to optimize the benefit-to-harm ratio for each individual patient.

The Polypharmacy Pandemic: Understanding the Scope

Defining Polypharmacy

Traditional definitions of polypharmacy range from the concurrent use of 5 or more medications to more nuanced classifications³:

Numerical polypharmacy: ≥5 medications (most common definition)
Problematic polypharmacy: Prescribing of multiple medications inappropriately or where intended benefit is not realized
Appropriate polypharmacy: Prescribing for complex or multiple conditions where medicines use is optimized and where the patient experiences good outcomes

Epidemiology and Impact

Recent epidemiological data reveals alarming trends:

40% of adults >65 years take ≥5 medications daily⁴
20% of emergency department visits in elderly patients are medication-related⁵
Annual healthcare costs attributable to polypharmacy exceed $100 billion in the United States⁶

🔑 Pearl: The number of potential drug-drug interactions increases exponentially with medication count: 2 medications = 1 interaction; 5 medications = 10 interactions; 10 medications = 45 interactions.

The Prescribing Cascade

The prescribing cascade phenomenon occurs when adverse drug reactions are misinterpreted as new medical conditions, leading to additional medications. Classic examples include:

ACE inhibitor → Dry cough → Antitussive
Diuretic → Gout → Allopurinol
Antipsychotic → Parkinsonism → Levodopa
NSAID → Hypertension → Antihypertensive

🔑 Oyster: Always consider medication-induced symptoms before adding new treatments. The temporal relationship between drug initiation and symptom onset is crucial.

The Physiology of Aging and Medication Metabolism

Pharmacokinetic Changes in Elderly Patients

Understanding age-related physiological changes is fundamental to effective de-prescribing:

Absorption:

Decreased gastric acidity affects drug dissolution
Reduced gastric motility delays absorption
Altered gastrointestinal blood flow

Distribution:

Decreased total body water (40-50% reduction)
Increased body fat percentage
Reduced plasma protein binding
Altered blood-brain barrier permeability

Metabolism:

Reduced hepatic mass and blood flow (30-40% decrease)
Decreased cytochrome P450 enzyme activity
Impaired first-pass metabolism

Elimination:

Progressive decline in glomerular filtration rate
Reduced renal tubular function
Altered drug transporter activity

🔑 Pearl: The "start low, go slow" principle applies not just to initiation but also to de-prescribing. Gradual dose reduction often prevents withdrawal syndromes and allows physiological adaptation.

STOPP/START Criteria: The Gold Standard

STOPP (Screening Tool of Older Persons' Prescriptions)

The STOPP criteria identify potentially inappropriate medications in elderly patients. The updated STOPP 2015 criteria include 80 explicit criteria across 13 physiological systems⁷:

Key Categories:

Indication-based criteria (A1-A3)
Cardiovascular system (B1-B14)
Antiplatelet/anticoagulant drugs (C1-C5)
Central nervous system (D1-D11)
Renal system (E1-E7)
Gastrointestinal system (F1-F6)
Respiratory system (G1-G4)
Musculoskeletal system (H1-H9)
Urogenital system (I1-I2)
Endocrine system (J1-J6)
Drugs that increase anticholinergic burden (K1-K4)
Drugs that increase risk of falls (L1-L2)
Analgesics (M1-M2)

START (Screening Tool to Alert to Right Treatment)

The START criteria identify potential prescribing omissions⁸:

High-Impact START Criteria:

A1: Warfarin/DOAC in chronic atrial fibrillation
A3: Antiplatelet therapy in diabetes with cardiovascular risk factors
B1: ACE inhibitor in heart failure
B3: Beta-blocker in ischemic heart disease
C1: Statin therapy in diabetes
E1: Proton pump inhibitor with peptic ulcer disease history

🔑 Hack: Use electronic prescribing systems with built-in STOPP/START alerts to catch inappropriate prescriptions in real-time.

The De-prescribing Process: A Systematic Approach

Step 1: Comprehensive Medication Review

The "Brown Bag" Review:

Request patients bring all medications, including over-the-counter drugs, supplements, and herbal remedies
Verify current medication list against multiple sources
Identify discrepancies and "ghost medications"

🔑 Pearl: Ghost medications are drugs patients believe they're taking but have actually discontinued, or drugs prescribed but never started.

Step 2: Risk-Benefit Assessment

High-Priority Targets for De-prescribing:

Medications with narrow therapeutic windows: Warfarin, digoxin, lithium
Drugs with high anticholinergic burden: Tricyclic antidepressants, antihistamines, antispasmodics
Fall-risk medications: Benzodiazepines, Z-drugs, alpha-blockers
Potentially inappropriate medications: Long-term PPIs, duplicate therapies

Step 3: Patient-Centered Decision Making

The De-prescribing Consultation Framework:

Explore patient concerns and preferences
Discuss medication burden and quality of life
Explain risks and benefits of continuation vs. discontinuation
Negotiate a trial of medication reduction
Establish monitoring parameters

🔑 Oyster: Patients often resist de-prescribing due to fear of symptom recurrence. Frame discussions around "optimizing" rather than "stopping" medications.

Step 4: Implementation and Monitoring

Tapering Strategies:

Gradual dose reduction: 25-50% every 1-2 weeks
Alternate day dosing: For long-half-life medications
Symptom-triggered approach: Patient-controlled tapering based on symptoms

Practical De-prescribing Strategies by Drug Class

Proton Pump Inhibitors (PPIs)

Indications for De-prescribing:

Long-term use (>8 weeks) without clear indication
Prophylactic use in low-risk patients
Duplicate acid suppression therapy

De-prescribing Protocol:

Assess original indication and current need
Gradual dose reduction: Full dose → Half dose → Every other day → Stop
Consider H2 receptor antagonist bridge therapy
Monitor for rebound acid hypersecretion

🔑 Pearl: Up to 70% of hospitalized patients on PPIs lack appropriate indication. The "PPI pause" during hospitalization provides an excellent de-prescribing opportunity.

Benzodiazepines

High-Risk Populations:

Adults >65 years (increased fall risk)
Patients with cognitive impairment
History of substance abuse
Concurrent CNS depressants

De-prescribing Protocol:

Assess dependence risk (duration >4 weeks suggests physical dependence)
Convert to long-acting equivalent (diazepam or clonazepam)
Reduce by 10-25% every 1-2 weeks
Monitor for withdrawal symptoms
Consider adjunctive therapies: CBT, relaxation techniques

🔑 Hack: The "benzodiazepine equivalence calculator" helps standardize conversion and tapering schedules.

Antipsychotics in Dementia

Regulatory Warnings:

FDA black box warning for increased mortality
Limited efficacy for behavioral symptoms
Significant metabolic and extrapyramidal side effects

De-prescribing Approach:

Identify and treat underlying causes: Pain, infection, medication effects
Implement non-pharmacological interventions
Gradual dose reduction: 25-50% every 2-4 weeks
Monitor for symptom recurrence
Engage family in behavioral management strategies

Cardiovascular Medications

Beta-blockers:

Appropriate de-prescribing: Patients without cardiovascular disease on beta-blockers for hypertension alone
Contraindications to de-prescribing: Post-MI, heart failure, arrhythmias

Statins:

Consider de-prescribing: Limited life expectancy (<1 year), intolerance, patient preference
Maintain therapy: Established cardiovascular disease, diabetes, high-risk primary prevention

🔑 Oyster: The "polypill" approach may actually facilitate de-prescribing by improving adherence and reducing pill burden for appropriate cardiovascular medications.

Special Populations and Considerations

Patients with Limited Life Expectancy

De-prescribing Priorities:

Discontinue medications with delayed benefits: Statins, bisphosphonates
Maintain symptom control: Analgesics, bronchodilators
Consider goals of care: Comfort vs. life prolongation

🔑 Pearl: Medications with time-to-benefit >6 months are prime candidates for discontinuation in patients with limited life expectancy.

Patients with Cognitive Impairment

Specific Considerations:

Anticholinergic burden assessment
Simplified dosing regimens
Caregiver education and support
Medication organizers and reminder systems

Perioperative De-prescribing

Preoperative Optimization:

Hold medications increasing bleeding risk: Antiplatelet agents, anticoagulants
Manage diabetes medications: Metformin, SGLT2 inhibitors
Optimize cardiac medications: Beta-blockers, ACE inhibitors

🔑 Hack: Create perioperative medication protocols with clear "stop," "continue," and "modify" categories for common medications.

Technology and De-prescribing

Clinical Decision Support Systems

Electronic Health Record Integration:

Real-time drug interaction alerts
Age-specific dosing recommendations
Automated STOPP/START screening
Medication reconciliation tools

Artificial Intelligence Applications

Emerging Technologies:

Predictive models for adverse drug events
Natural language processing for medication extraction
Machine learning algorithms for personalized de-prescribing

🔑 Pearl: AI-assisted de-prescribing tools show promise but require clinical validation and physician oversight to ensure safety and appropriateness.

Barriers to De-prescribing and Solutions

Physician Barriers

Common Obstacles:

Time constraints
Lack of training in de-prescribing
Fear of adverse outcomes
Fragmented care
Medical-legal concerns

Solutions:

Standardized de-prescribing protocols
Interdisciplinary team approaches
Protected time for medication reviews
Continuing education programs

Patient Barriers

Resistance Factors:

Attachment to medications
Fear of symptom recurrence
Lack of understanding
Multiple prescribers

Engagement Strategies:

Motivational interviewing techniques
Patient education materials
Shared decision-making tools
Peer support programs

🔑 Oyster: The "medication possession ratio" can identify patients likely to be adherent to de-prescribing recommendations.

Quality Measures and Outcomes

Clinical Outcomes

Primary Endpoints:

Reduction in adverse drug events
Decreased healthcare utilization
Improved quality of life scores
Reduced medication costs

Secondary Endpoints:

Cognitive function improvement
Reduced fall risk
Better medication adherence
Enhanced patient satisfaction

Quality Indicators

Process Measures:

Percentage of patients with medication review
Time to medication optimization
Number of inappropriate medications discontinued

Outcome Measures:

30-day readmission rates
Emergency department visits
Mortality rates
Patient-reported outcomes

🔑 Pearl: The "Number Needed to Treat" (NNT) for de-prescribing interventions is often lower than many therapeutic interventions, highlighting the significant impact of medication optimization.

Implementation Strategies

Institutional Approaches

Multidisciplinary Teams:

Physicians: Clinical decision-making
Pharmacists: Medication expertise
Nurses: Patient education and monitoring
Social workers: Psychosocial support

Quality Improvement Initiatives:

Medication reconciliation programs
Deprescribing champions
Regular medication reviews
Patient safety rounds

Educational Interventions

Professional Development:

De-prescribing workshops
Case-based learning
Simulation training
Peer review activities

Patient Education:

Medication literacy programs
Shared decision-making tools
Community outreach
Digital health resources

🔑 Hack: The "medication timeout" approach—temporarily stopping a medication during hospitalization—can reveal unnecessary drugs and facilitate de-prescribing discussions.

Future Directions and Research

Emerging Concepts

Precision De-prescribing:

Pharmacogenomic testing
Biomarker-guided therapy
Personalized risk assessment

Digital Health Solutions:

Mobile applications for medication management
Telemedicine for monitoring
Wearable technology for symptom tracking

Research Priorities

Key Areas for Investigation:

Long-term outcomes of de-prescribing interventions
Cost-effectiveness analyses
Patient-centered outcome measures
Implementation science studies
Comparative effectiveness research

🔑 Pearl: The field of de-prescribing is rapidly evolving, with new evidence emerging regularly. Stay current with systematic reviews and meta-analyses to inform evidence-based practice.

Conclusion

The art of de-prescribing represents a fundamental competency for modern internal medicine practitioners. As healthcare systems worldwide grapple with the challenges of polypharmacy, the ability to systematically identify, assess, and safely discontinue inappropriate medications becomes increasingly valuable.

Effective de-prescribing requires a paradigm shift from the traditional "more is better" approach to a thoughtful, patient-centered optimization strategy. The integration of validated tools like STOPP/START criteria, systematic approaches to medication review, and interdisciplinary collaboration creates a framework for safe and effective medication optimization.

For critical care practitioners, mastering de-prescribing principles is particularly relevant given the complex medication regimens common in intensive care settings. The skills developed in systematic medication review translate directly to improved patient outcomes, reduced healthcare costs, and enhanced quality of care.

The future of de-prescribing lies in the integration of technological solutions, personalized medicine approaches, and robust implementation science. As we continue to advance our understanding of medication optimization, the art of de-prescribing will undoubtedly evolve into an increasingly sophisticated and essential clinical skill.

🔑 Final Pearl: De-prescribing is not about doing less medicine; it's about doing better medicine. The goal is always to optimize the therapeutic regimen for each individual patient, maximizing benefits while minimizing harm.

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Sunday, July 6, 2025