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The success of modern medicine comes with a cost of increased morbidity. Patients are increasingly diagnosed with conditions which, through knowledge gained from randomised controlled trials, we know can be managed successfully with drugs to reduce complications and premature mortality. Multimorbidity is now commonplace, with half of all people aged over 65 years having at least three co-existing conditions, and a fifth having five or more.1 For the patient that might mean 10 or more different drugs to take in the day. Such polypharmacy may be associated with a high risk of interactions, adverse events (17% of hospital admissions in people aged over 65 years result from adverse drug reactions) and even underprescribing.2,3
It is recognised that clinical guidelines, care pathways and even clinician remuneration systems have contributed to the increase in polypharmacy.4 For some patients, taking a large number of drugs is relatively straightforward, well-managed and results in improved health outcomes (“appropriate polypharmacy”).4 On the other hand, for another patient the same combination of medicines might be seen as “problematic polypharmacy” resulting from biological, social and psychological characteristics of the patient. As such, appropriate polypharmacy requires an individualised, patient-centred approach that is shared across the healthcare system. Medicines optimisation is the label given to a process that allows patients to gain most net benefit from taking medication. Unfortunately, current professional and institutional silos add to the challenge of managing medicines across boundaries, and the components of a successful medicines optimisation process have not clearly been defined.
However, a significant element of the medicines optimisation process must include the notion of stopping medication, sometimes known as “deprescribing”.5 At worst, this can be the thoughtless termination of drugs on the basis of arbitrary thresholds such as age; at best, it involves identifying the point at which drugs are no longer providing a worthwhile benefit. Many medicines are often continued beyond the point at which they are beneficial and may actually be causing harm. Yet this is an area with very little evidence and one of the most difficult decisions facing patients and prescribers is in agreeing when and how to stop. One key message from the King's Fund report on polypharmacy is that when reviewing medication (in primary, secondary or community care setting), healthcare professionals should always consider if treatment can be stopped and to recognise that ‘end-of-life’ considerations apply to many chronic diseases, cancer-related conditions and frailty. The latter is a term we shall hear more of in the coming years as it moves from a poorly defined abstract concept to one that proves central to our notion of health in older age. The emphasis on ensuring that patients are taking the correct treatment for their condition must focus as much on giving prescribers the support, evidence and confidence to stop medication as it currently does on starting and maintaining medication.