Deprescribing to optimise drug therapy
Debi Bhattacharya is Professor of Behavioural Medicine at the University of Leicester, UK. As a former primary care pharmacist, she has experience of both practice and research into deprescribing. In this series of short videos, she explains what deprescribing involves, why it is important for optimal medicines’ use and how a new study will test a novel intervention designed to support proactive deprescribing.
Deprescribing – reactive and proactive
“Deprescribing is often thought of as a homogenous behaviour ……. but in 2018 we defined two distinct behaviours – …. ‘reactive’ and ‘proactive’ deprescribing”, says Professor Bhattacharya. Reactive deprescribing is when a medicine is stopped in response to a clinical trigger, whereas proactive deprescribing is when a medicine is stopped because the risk of future harm outweighs the likelihood of future benefit.
“So, it’s a much more complex decision that absolutely has to be made in partnership with a patient”, she emphasises.
Clinical guidelines emphasise situations when medicines should be started but not when or how to stop medicines, she comments.
Barriers and enablers for deprescribing
“There are there are numerous barriers and enablers – things that will help practitioners and patients to proactively stop a medicine but …. there’s no one-size-fits all”, says Professor Bhattacharya. Understanding the factors that operate in any given situation is essential if effective interventions are to be devised. For example, in one hospital project, both patients and pharmacists felt that doctors should initiate the deprescribing discussion. In contrast, an opioid deprescribing project in primary care is being largely led by pharmacists, who are also initiating the deprescribing discussions.
It is a common misconception that patients are resistant to having their medicine stopped proactively, although when deprescribing interventions have been offered to patients in trials, in the majority of cases they’ve been rejected by the patient. Having sufficient time and skill to discuss the issues in a meaningful way may be the key to success here.
CHARMER – a different kind of deprescribing intervention study
Many previous studies of proactive deprescribing interventions have failed to demonstrate positive outcomes. The CHARMER study – Comprehensive geriatrician-led medication review – has developed a new approach. Five critical factors identified by prescribers and patients as being key to success, have been built into the study. They are:
- Ensuring that practitioners feel that deprescribing is a priority for their employer
- Addressing the misconception that patients are resistant to deprescribing
- Overcoming the feeling amongst pharmacists that it is safer to do nothing rather than to stop a medicine that’s currently causing no harm, even though it is likely that in the future it will cause harm
- Provision of protected time for pharmacists and geriatricians to meet to discuss patients that may benefit from deprescribing
- Provision of feedback so that practitioners see the results of their efforts.
The CHARMER study will involve 24 hospitals in England and will be completed in 2025.
About Professor Debi Bhattacharya
Professor Bhattacharya leads a research team that focuses on applying behaviour change methods to improve health outcomes. The team works with a wide range of funding bodies and organisations to design and implement behaviour change strategies for patients and healthcare professionals. In addition, she is the director of Leicester’s independent prescribing course for pharmacists.