Executive Summary

Medicines play a critical role in preventing illness, managing chronic conditions, curing disease, and offering symptomatic relief that can significantly improve a person's functional capacity and quality of life. However, all medicines have the potential to cause harm. The use of a medicine is typically a trade-off between benefits and risks. Evidence suggests that an increasing number of medicines was associated with an increased risk of medicine-related harm [3].

Existing clinical practice guidelines are largely single-disease-focused and do not reflect the reality of multimorbidity (defined as the presence of two or more chronic health conditions) in practice [4]. The management of multimorbidity is often complex. Strictly following all the recommendations in current single-disease guidelines without incorporating individual preferences and circumstances can result in an overwhelming treatment burden for older people with multimorbidity [5].

For people with chronic diseases, the assessment of the benefits and risks of medicines is likely to evolve throughout their disease journey depending on their treatment experience, clinical situation, and changing needs [6]. As such, appropriate monitoring is essential as a medicine that was once beneficial may become less suitable over time. These medicines are referred to as potentially inappropriate medicines (PIMs) which are medicines where the risk of harm outweighs the benefits, that are used instead of a safer and more effective alternative or are used without an existing evidence-based indication [7, 8]. The use of PIMs is highly prevalent among older people worldwide [9, 10]. Multimorbidity and concurrent use of multiple medicines were associated with the high prevalence of PIM use [9, 11]. The use of PIMs in older people leads to negative health outcomes, including adverse drug events [12], hospitalisations [12, 13], and high healthcare expenses [14]. Among older people with dementia, the use of PIMs significantly increased the risk of falls and fall-related injuries [15].

Deprescribing acknowledges that the need for medicines is dynamic as an individual's circumstances may evolve with time. It is a systematic process to optimise an individual's medication regimens with the ultimate goal of reducing harm as well as improving outcomes and quality of life [16]. Prescribing and deprescribing are two interconnected aspects of medicine management. While prescribing involves initiating medicines and deprescribing involves discontinuing or reducing the dose of a medicine, both are intended to improve health outcomes. Rational prescribing emphasises the continuous monitoring of treatment for efficacy and adverse outcomes.

For optimal patient care and to ensure continuity of care, all healthcare providers involved in a patient's care must collaborate and align their treatment plans [17]. Any modifications to a person's medication regimen (whether prescribing or deprescribing) should be communicated to other healthcare providers involved in a patient's care with sufficient information to enable other healthcare providers to deliver the best possible care to their mutual patient.

Prescribers should also document any discussions held with other healthcare providers regarding the prescribing and deprescribing process. This includes recording the rationale for changes, the agreed-upon approach for medicine withdrawal (e.g. dose tapering, order of withdrawal), and the monitoring plan. Collaboration and communication with all prescribers help to maintain a unified, person-centred approach and avoid medication misadventures.

A critical attribute of deprescribing is person-centred care [18]. Person-centred care involves meeting the multidimensional needs and preferences of older people dependent on care, by considering the needs, goals, and abilities of the person, their carers as well as their families [19-21]. In the context of deprescribing, person-centred care must take into account an individual's goals, values, and preferences along with research evidence, cost-effectiveness, and value-based care in the decision-making process [22]. For older people who are receiving care from family members and/or formal or informal carers, the views and preferences of their families and/or carers are a part of the key aspects of person-centred care. The implementation of person-centred care can help to identify and contribute to meeting the needs of the family and/or carers of older people [23].

Values and preferences may differ substantially among people. Therefore, the decision to deprescribe should be personalised. Deprescribing should be a shared, collaborative decision-making process between individuals and healthcare providers involving the following steps [24]:

1. Creating awareness that options exist, and a decision can be made
2. Discussing the options and their potential benefits and harms
3. Exploring preferences for (attributes of) different options
4. Making the decision together with the person, their families, and/or carers

The decision to deprescribe appeared to be influenced by communication skills (e.g. risk, uncertainty, prognosis communication) [25, 26], the perceived experience of the healthcare provider [27], and a trusting relationship between the individual and the healthcare provider [26]. Treatment plans, including decisions to deprescribe, should be revisited periodically to adapt to the individual's changing needs and preferences [24]. The process should emphasise open communication, respect for the individual's autonomy, and shared responsibility in decision-making.

The Geriatric 5Ms is a framework to optimise the care for older people, focusing on five key domains. This framework [28] aligns well with deprescribing efforts, emphasising a holistic approach to managing medicines while considering broader aspects.

Through a person-centred approach to deprescribing, previously unrecognised health priorities and concerns may emerge. In some cases, this process may lead to the initiation of new medicines that offer potential benefits while discontinuing others that are no longer necessary.

The prescribing competencies framework currently exists, which describes the competencies required for healthcare professionals to prescribe medicines judiciously, appropriately, safely, and effectively [29]. Reviewing the outcomes of treatment is one of the key prescribing competency areas which includes stopping or modifying existing medicines and other treatments where appropriate. In addition to healthcare professionals often expressing low confidence and self-efficacy for deprescribing [30, 31], there is a lack of focus on teaching and assessing deprescribing skills within healthcare curricula in many countries [32]. To address these barriers, specific competencies required for deprescribing are now being proposed as part of the essential curriculum for pre-registration healthcare professionals in their entry-to-practice degree programs [1]. Deprescribing has been described as a key competency in medicine, dentistry, nursing, and pharmacy, that is viewed to be inextricably linked to prescribing to achieve high-quality healthcare. Farrell et al proposed the following seven deprescribing competencies to be applied by healthcare professionals in collaboration with individuals, their families, and/or carers within an interprofessional care team (see below).

Each of the seven competencies was expanded in detail in the paper, with descriptions of the knowledge and skills required to meet each competency [1]. Integrating this deprescribing competency framework into the education of other allied healthcare professionals (e.g. physiotherapists, occupational therapists, dietitians, speech-language pathologists, social workers) is also valuable as they play crucial roles in the holistic care of older people. Allied healthcare professionals can identify situations where deprescribing of a particular medicine may be considered [1].

Deprescribing in practice is challenging as it involves complex considerations in a fast-paced environment (some settings may be resource-poor), taking a person-centred approach that understands the individual's preferences in a particular situation, and coordinating care with multiple prescribers [33]. Drug class-specific deprescribing guidelines and algorithms are available to guide the process such as those developed by Primary Health Tasmania and New South Wales Therapeutic Advisory Group in Australia as well as the Bruyère Research Institute in Canada [34-36]. Evidence-based deprescribing clinical practice guidelines developed using a rigorous process exist for a number of drug classes, including cholinesterase inhibitors and memantine [37], opioid analgesics [38], benzodiazepine receptor agonists [39], proton-pump inhibitors [40], diabetes medicines [41], and antipsychotics [42]. Expert guidance on deprescribing antidepressants, benzodiazepines, gabapentinoids, and Z-drugs is also available [43].

Medicine management is often complex, with barriers existing for both prescribing and deprescribing. A key challenge in practice is the absence of robust evidence to guide decision-making, such as the lack of evidence in the management of gout and rheumatoid arthritis. Additionally, barriers specific to the application of deprescribing guidelines in clinical practice include time constraints and competing priorities during a consultation [44]. When a person is prescribed multiple medicines, it becomes increasingly challenging for healthcare providers to approach deprescribing, as existing drug-specific guidelines may lack guidance on how to manage the deprescribing of multiple medicines holistically. The complexity of discussing and implementing deprescribing for people with multiple morbidities and an increased risk of poor communication between parties involved in an individual's care have been cited in the literature [45]. When prescribing is directly influenced by individual requests for specific medicines, the resulting resistance or refusal to deprescribe medicines may also be a barrier to medicine cessation [46]. In addition, people may feel uneasy about deprescribing medicines prescribed by another healthcare professional, which may be a kind of loyalty to this person [47]. Similarly, physicians may be reluctant to deprescribe medicines prescribed by another healthcare professional or specialist due to concerns about undermining another practitioner's treatment plan [48]. For healthcare professionals, there are major concerns arising from deprescribing about undertreatment, underdosing, and not complying with the recommendations from existing treatment guidelines, particularly in the absence of clear and consistent high-quality evidence for deprescribing [49].

The overarching goal of this guideline is to bridge the gap from research to practice by translating research evidence into recommendations that are actionable, acceptable, feasible, and implementable in care practice for older people. Clinical practice guidelines for deprescribing exist for key drug classes. Our goal is to provide broad guidance for deprescribing medicines, that complements more detailed drug-specific deprescribing guidance, disease-specific therapeutic guidelines, and non-pharmacological management resources. The current guideline aims to provide a summary of recommendations for when, how, and for whom deprescribing may be considered and offered, with a shared decision-making process involving individuals, their family members, carers, or support persons to ensure decisions align with individual health goals, values, and preferences. Additionally, since deprescribing is not without risks, this guideline aims to identify monitoring requirements during the deprescribing process and address ongoing treatment needs as applicable. Although this guideline has been developed with a focus on medicines commonly used by people aged 65 and older in Australia, the guideline draws on evidence from studies conducted globally. We anticipate that this guideline will have international relevance. However, variations in medicine availability, regulatory frameworks and clinical practices may necessitate adaptations to align with country-specific treatment guidelines.

For section information, refer to “Guideline structure”.