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Module 13: Pharmacotherapeutic Management and Optimization
Section 3: Managing Polypharmacy and Deprescribing
A masterclass in the art of subtraction. We will explore systematic approaches to identifying and eliminating unnecessary medications, reducing pill burden, and mitigating the risks of polypharmacy, especially in older adults.
SECTION 13.3
The Art of Subtraction: From Medication Accumulator to Clinical Architect
Reclaiming Therapeutic Simplicity and Safety Through Deprescribing.
13.3.1 The “Why”: Polypharmacy as a Prescribed Epidemic
In modern medicine, we have become masters of addition. For nearly every diagnosis, there is a guideline-recommended medication. A patient with a heart attack leaves the hospital with a beta-blocker, an ACE inhibitor, a high-intensity statin, dual antiplatelet therapy, and perhaps an aldosterone antagonist. A patient with diabetes is soon on metformin, an SGLT2 inhibitor for renal protection, a GLP-1 agonist for cardiovascular benefit, and a statin. Each of these additions is rational, evidence-based, and correct in isolation. Yet, over a lifetime of accumulating diagnoses and specialists, this logical addition results in a phenomenon that is anything but logical: polypharmacy.
Polypharmacy, commonly defined as the routine use of five or more medications, is not a fringe issue; it is the standard of care for millions, especially older adults. Over 42% of adults over 65 take five or more prescription drugs, and nearly 20% take ten or more. This is not a sign of patient non-compliance or physician negligence. It is the natural, emergent outcome of a healthcare system that is highly effective at starting medications but has no systematic process for stopping them. The result is a silent, prescribed epidemic. As the number of medications increases, the risk of adverse drug events, drug-drug interactions, falls, hospitalizations, and mortality increases exponentially.
The most insidious driver of this epidemic is the prescribing cascade. This occurs when a side effect of one drug is misinterpreted as a new medical condition, leading to the prescription of a second drug to treat the side effect. A classic example: Amlodipine is prescribed for hypertension, causing peripheral edema. The edema is mistaken for fluid overload, and furosemide is prescribed. Furosemide causes urinary incontinence, so oxybutynin is prescribed. Oxybutynin, an anticholinergic, causes confusion and dry mouth. The patient is now on four drugs when they only needed one. Breaking this cycle requires a fundamental shift in mindset. As a pharmacist with a CPA, you are uniquely positioned to lead this shift. Your role is to become a master of subtraction. Deprescribing—the supervised process of dose reduction or discontinuation of a medication that may be causing harm or is no longer providing benefit—is not a sign of therapeutic failure. It is an advanced, proactive clinical skill. It is the art of sculpting a medication regimen down to its essential, beneficial core, and it is one of the most profound acts of patient safety you will perform.
Pharmacist Analogy: The Overgrown Garden
Imagine a patient’s medication list is a garden. When the patient is young and healthy, the garden is mostly empty. Then, a diagnosis of hypertension is made, and a skilled gardener (the primary care physician) plants a sturdy, reliable oak tree (an ACE inhibitor). A few years later, diabetes develops, and a row of productive tomato plants (metformin) is added. Both are excellent choices.
But over the decades, other gardeners arrive. A cardiologist plants a dense, sprawling vine (amiodarone) without consulting the first gardener. A urologist adds a thirsty, fast-growing shrub (oxybutynin). A pain specialist plants what looks like a beautiful flower but turns out to be an invasive weed (a long-term opioid). A short-term medication, like a patch of annuals (a PPI for a GI bleed), is never removed and reseeds itself year after year. Soon, the garden is a chaotic, overgrown mess. The original oak tree is being choked by the vine. The tomatoes are shaded out and producing little fruit. Weeds (side effects) are everywhere. To combat the weeds, more chemicals (drugs to treat side effects) are sprayed, which harms the good plants as well.
The patient, the owner of the garden, just knows that it’s difficult to walk through and doesn’t feel healthy anymore. As a collaborative practice pharmacist, you are not just another person with a seed packet. You are the Master Gardener. Your job is to step back, survey the entire ecosystem, and develop a plan. You don’t just start ripping plants out. You use your expertise:
- You identify the weeds: You recognize the high-risk, inappropriate medications (the benzodiazepine, the glyburide).
- You prune what’s overgrown: You see that a medication’s dose is too high for the patient’s current state (renal function has declined) and carefully cut it back.
- You remove what’s no longer bearing fruit: You identify medications that are no longer providing benefit or whose original indication is gone (the PPI).
- You check the soil: You order labs to see how the ecosystem is functioning (BMP, LFTs).
This process of thoughtful, systematic weeding, pruning, and thinning is deprescribing. It is not destruction. It is the art of restoring the garden to a healthy, intentional, and beautiful state where the truly beneficial plants can thrive.
13.3.2 The Deprescribing Toolkit: Identifying Targets for Discontinuation
Effective deprescribing is not a haphazard process of randomly stopping medications. It is a systematic, evidence-based review of a patient’s entire medication list through the lens of their current clinical status, goals of care, and life expectancy. Fortunately, we are not navigating this complex landscape without maps. Clinical researchers have developed several powerful tools to help us identify Potentially Inappropriate Medications (PIMs). Mastering these tools is the first step toward becoming a skilled deprescribing practitioner.
Deep Dive 1: The AGS Beers Criteria®
The American Geriatrics Society (AGS) Beers Criteria® is perhaps the most famous deprescribing tool in the world. It is an explicit list of PIMs that are best avoided in older adults, either in general or in those with specific conditions. It’s important to understand what the Beers Criteria is and is not. It is not a rigid set of rules; it is a clinical guidance tool. A medication on the list is not automatically “wrong,” but its use requires a strong, documented rationale that the benefits clearly outweigh the risks for that individual. In your practice, the Beers Criteria should serve as your primary “red flag” system. When you see a patient on one of these medications, it should trigger an immediate, in-depth review.
Masterclass Table: Key Drug Classes from the AGS Beers Criteria® (2023 Update)
| Drug/Class to Avoid in Most Older Adults | Rationale (The “Why”) | Safer Alternatives or Management Strategy |
|---|---|---|
| First-Generation Antihistamines (Diphenhydramine, Hydroxyzine) |
Highly anticholinergic; high risk of confusion, dry mouth, constipation, sedation, and falls. Clearance is reduced in older adults. | |
| Benzodiazepines (BZDs) (Lorazepam, Alprazolam, Diazepam) |
Increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Risk increases with longer duration of use. | |
| Proton-Pump Inhibitors (PPIs) (Omeprazole, Pantoprazole) |
Risk of C. difficile infection, pneumonia, and bone loss/fractures with long-term use. Many patients lack a clear, ongoing indication for therapy. | |
| Long-Acting Sulfonylureas (Glyburide, Glimepiride) |
High risk of severe, prolonged hypoglycemia in older adults due to long duration of action and active metabolites that are renally cleared. | |
| Non-COX-selective NSAIDs, Oral (Ibuprofen, Naproxen, Diclofenac) |
Increased risk of GI bleeding, peptic ulcer disease, and kidney injury. Can exacerbate heart failure and hypertension. |
Deep Dive 2: The STOPP/START Criteria
If the Beers Criteria is a static list of “drugs to avoid,” the STOPP/START criteria (Screening Tool of Older People’s Prescriptions / Screening Tool to Alert to Right Treatment) are a more dynamic, physiology-based tool. It consists of two parts:
- STOPP: A list of criteria that identify potentially inappropriate prescriptions based on the patient’s specific diagnoses (e.g., “Beta-blocker in a patient with asthma”).
- START: A list of criteria that identify prescribing omissions, helping you find where a beneficial drug is missing (e.g., “Statin therapy is missing in a patient with clinical ASCVD”).
This dual approach is powerful because it encourages you to think about both subtraction and addition, ensuring that as you remove inappropriate medications, you are also confirming that all necessary, evidence-based therapies are in place.
Masterclass Table: Examples from the STOPP/START Criteria
| Criteria Type | Example Scenario | Clinical Rationale | Pharmacist Action |
|---|---|---|---|
| STOPP | Any duplicate drug class (e.g., two NSAIDs, two SSRIs, an ACEi and an ARB together). | Offers no additional efficacy and significantly increases the risk of adverse effects. This is a common error. | Identify the duplication, determine which agent is more appropriate (or if either is needed), and discontinue one. |
| STOPP | Use of a loop diuretic for dependent ankle edema with no clinical signs of heart failure. | The edema is likely due to venous insufficiency (or a drug like amlodipine), not fluid overload. A diuretic will not fix the underlying problem and risks dehydration and electrolyte imbalance. | Investigate the cause of the edema. Recommend non-pharm interventions (compression stockings, leg elevation). Discontinue the diuretic. |
| START | Patient with documented atrial fibrillation is not on any form of anticoagulation. | High risk of ischemic stroke that is significantly reduced by anticoagulation. This is a major care gap. | Calculate the patient’s CHA₂DS₂-VASc score to confirm the indication. Assess bleeding risk. Initiate guideline-appropriate anticoagulation (likely a DOAC). |
| START | Patient with osteoporosis and a history of fracture is not on a bisphosphonate or other agent. | High risk of subsequent, potentially debilitating fractures. Pharmacotherapy is proven to reduce this risk. | Confirm bone density via DXA scan results. Ensure calcium and vitamin D intake are adequate. Initiate first-line therapy (e.g., alendronate), ensuring proper administration counseling. |
13.3.3 The 5-Step Deprescribing Framework: A Practical Guide to Subtraction
Identifying a potentially inappropriate medication is the first step. Successfully discontinuing it requires a structured, collaborative process that prioritizes safety and respects the patient’s beliefs and experiences. This 5-step framework provides a repeatable workflow for any deprescribing encounter.
1
Reconcile & Review
Perform a best-possible medication history to create the one “source of truth” medication list, including prescriptions, OTCs, supplements, and PRNs. Your community pharmacy skills are paramount here. You are looking for what the patient actually takes, not just what’s on their profile.
2
Identify & Prioritize Targets
Apply your deprescribing toolkit (Beers, STOPP/START) to the reconciled list. Identify all PIMs. Then, prioritize them. Don’t try to stop five drugs at once. Start with the medication causing the most harm or offering the least benefit (the “low-hanging fruit”). High-risk drugs like benzodiazepines, anticholinergics, and sulfonylureas should be at the top of your list.
3
Assess Benefit vs. Risk & Create a Plan
For each prioritized target, conduct a patient-specific benefit/risk assessment. Does this drug still have a valid indication? Is it achieving its goal? What is the risk of continuing it vs. the risk of stopping it? Based on this, design a specific, actionable deprescribing plan. Will it be an abrupt stop or a gradual taper? What monitoring is required?
4
Collaborate & Counsel
This is the most critical step. Deprescribing is a team sport. You must achieve buy-in from both the patient and the primary provider. This requires clear, respectful communication that focuses on shared goals of safety and well-being. This is where you use your motivational interviewing and communication skills.
5
Monitor, Document, & Follow-Up
Implement the plan and monitor closely for withdrawal effects or the return of the condition being treated. Document your rationale, the plan, and the outcome in the patient’s chart. Schedule a specific follow-up to assess the impact of the change. Deprescribing is not a single event; it is a process with a clear beginning, middle, and end.
The Deprescribing Conversation: Scripts for Success
How you frame the conversation is everything. You are not “taking away” a medication; you are “optimizing” the regimen.
Talking to the Patient:
- Acknowledge their experience: “I know you’ve been taking this sleeping pill for a long time, and it may have been helpful in the past.”
- Focus on safety and shared goals: “As we get older, our bodies process medications differently. My main goal is to keep you safe and prevent falls. Research has shown that this particular medication can affect balance and memory in some people. I’m concerned it might be doing more harm than good now.”
- Propose a trial: “I’m not suggesting we stop it abruptly. What I’d like to propose is that we work together on a very slow plan to reduce the dose and see how you feel. The goal is to be on the fewest medications necessary to keep you healthy. How does that sound as a starting point?”
Communicating with the Provider (e.g., via EHR message):
- Be concise and evidence-based: “Dr. Smith, I am seeing your patient, Mrs. Jones, in my polypharmacy clinic under our CPA. I noted she is on oxybutynin 5mg TID for urinary incontinence.”
- State the risk clearly: “Given her age and recent complaints of confusion, this high-anticholinergic-burden medication is a concern and is listed on the AGS Beers Criteria as a medication to avoid. I believe it may be contributing to her cognitive symptoms.”
- Provide a clear, actionable plan: “I would like to initiate a slow taper off the oxybutynin over the next 4 weeks. I will provide the patient with non-pharmacologic strategies for incontinence and will monitor for any worsening of urinary symptoms. Please let me know if you have any objections to this plan.”
13.3.4 Deprescribing in Action: Clinical Scenarios
Let’s apply the 5-step framework to two common and complex clinical scenarios you will undoubtedly encounter in your practice.
Case 1: The “Dizzy and Falling” Patient
Patient: An 84-year-old woman, Mrs. Davis, is referred to your clinic by her daughter, who is concerned about two recent falls and increasing confusion over the last six months.
Past Medical History:
- Type 2 Diabetes
- Hypertension
- Osteoarthritis
- Insomnia
- Stress Incontinence
Medication List:
- Metformin 1000mg BID
- Glyburide 10mg daily
- Lisinopril 20mg daily
- Amitriptyline 25mg QHS (for sleep)
- Oxybutynin IR 5mg TID
- Naproxen 500mg BID PRN pain
- Lorazepam 0.5mg QHS PRN sleep
Step 1 (Reconcile): You confirm with the patient and her daughter that this list is accurate. She uses the lorazepam about 3-4 times per week.
Step 2 (Identify & Prioritize): Your “Beers Criteria” alarm is blaring.
- Highest Priority (Highest Harm): Glyburide (high risk of prolonged hypoglycemia), Amitriptyline (highly anticholinergic and sedating), Lorazepam (fall risk, cognitive impairment).
- High Priority: Oxybutynin (high anticholinergic burden contributing to confusion).
- Concern: Naproxen (risk to kidneys, GI tract, BP).
Step 3 (Assess & Plan):
- Glyburide: Benefit (glucose lowering) is massively outweighed by the risk of a fall-inducing hypoglycemic event. Plan: Discontinue immediately and switch to a safer agent (e.g., DPP-4 inhibitor, or increase metformin if eGFR allows).
- Amitriptyline: Used for sleep, not depression. High risk, low-quality benefit. Plan: Taper and discontinue.
- Lorazepam: Contributes to sedation and falls. Plan: Slow taper is essential.
- Oxybutynin: Contributes to anticholinergic burden. Plan: Taper and discontinue, replace with non-pharm strategies.
Step 4 (Collaborate & Counsel): You explain to Mrs. Davis and her daughter, “I’ve identified four medications that are known to be risky for ladies your age and are very likely contributing to the dizziness and falls. My goal is to carefully stop them, one by one, to make you safer. We will start with the diabetes pill, glyburide, as it poses the most immediate danger.”
Step 5 (Monitor & Follow-Up): You provide a written tapering schedule. You schedule a follow-up call in one week and a return visit in one month. You will monitor for withdrawal (from BZD) and return of symptoms (incontinence), but the primary goal is preventing falls.
Quantifying the Risk: Anticholinergic Burden
You can make your assessment more objective using an Anticholinergic Burden Scale (like the ACB Scale). Amitriptyline scores a 3 (high), and Oxybutynin scores a 3 (high). A total score of 3 or more is associated with an increased risk of cognitive impairment and mortality. Mrs. Davis has a score of 6. This is a powerful, objective piece of data to share with the provider when recommending discontinuation.
