Introduction

On 30 June 2020, one in six (approximately 4.2 million) Australians were aged 65 and over [50]. At least 250,000 hospital admissions in Australia annually are medicine-related, with the majority involving older people [51]. Two-thirds of these unplanned hospital admissions are potentially preventable [51]. The use of multiple concurrent medicines is especially prevalent among older people and is commonly referred to as polypharmacy [52]. Polypharmacy affects almost one million older Australians, and the number of people affected increased by 52% from 2006 to 2017 [53]. While some medicines are clinically indicated, polypharmacy in older people is associated with an increased risk of hospitalisations, functional impairment, geriatric syndromes (including confusion, falls, incontinence, frailty) and mortality [54]. Paradoxically, polypharmacy is also associated with under-prescribing, where people may not receive indicated medications for treating or preventing a condition due to concerns about further complicating their regimen [55].

Medicine safety is a health priority for Australia's ageing population. Medicine use in older people is a fine balance of managing the underlying symptoms or risks in accord with the older person's preferences, while at the same time, minimising drug-related problems through monitoring, reducing pill burden and avoiding unnecessary medicine use. Older people are at an increased risk of adverse drug events and harm arising from potentially inappropriate medicine use and adverse drug interactions [56-60]. Adverse drug events are defined as any injuries resulting from medical intervention related to a drug [61] which includes physical harm, mental harm, or loss of function. The incidence of adverse drug events increases with the number of medicines used [62]. Adverse drug events are frequently under-recognised and can be mistaken for symptoms requiring further treatment, which leads to inappropriate prescribing cascades or may be simply dismissed as an unavoidable consequence of ageing.

The reasons why older people are at an increased risk of medicine-related harm are multifactorial and include factors such as drug-drug interactions, prescribing cascades, frailty, physiological changes, and multimorbidity [63, 64]. The balance of benefits and risks associated with medicines shifts as people age, particularly in the management of chronic diseases. In these cases, deprescribing can play a crucial role in optimising care. Deprescribing is a person-centred process of withdrawing medicines that are either no longer required or where the risk of harm outweighs the risk of benefit, with the ultimate goal of improving quality of life [18]. It involves carefully evaluating whether the ongoing use of certain medicines continues to offer more benefits than risks, particularly as an individual's circumstances change. A medicine clinically indicated for an individual's condition at a specific point in time may not be appropriate or necessary in the future. As such, ongoing monitoring is important to adapt health management strategies based on their changing needs, goals, preferences, or priorities over time. Deprescribing provides an opportunity for medication reconciliation and optimising medication regimens to ensure the medicines are prescribed based on the best available evidence and aligned with the individual's goals, on the proposition that the person is likely to derive more benefit than harm.

Deprescribing is an intervention that is acceptable to older people, with over 90% of older people across a range of settings stating that they would like to stop one of their medicines if their doctor said it was possible [65]. However, deprescribing in clinical practice is a challenging process [63], and health professionals consistently cite the lack of synthesised evidence or guidance as a barrier to deprescribing [66]. Deprescribing is not a decision made in isolation but requires careful consideration of various individual factors, including overall health, quality of life, goals, preferences, affordability, pill burden, health literacy, and adherence to the current medication regimen [63]. Existing resources that support health professionals in identifying potential target medicines for deprescribing include lists of high-risk medicines and decision aids [67]. Lists that identify high-risk medicines in older people can prompt prescribers to re-consider these potentially high-risk medicines. These lists do not require specialist in-depth knowledge; however, they are general in nature and do not provide specific advice or information on how to withdraw identified medicines in an individual and how to monitor the process of medicine withdrawal [67]. Most of these lists also do not suggest safer alternative treatments or therapies.

The current clinical practice guideline (‘guideline’) aims to provide a resource for healthcare providers to guide the deprescribing of commonly encountered medicines in routine clinical care. It provides information to support healthcare providers in determining whether deprescribing is appropriate for specific drug classes as well as including overarching information for deprescribing in the context of polypharmacy or multiple drug classes. The target audience for the guideline is health practitioners involved in the care of older people (≥ 65 years), particularly medical practitioners, nurse practitioners, pharmacists, and other non-medical prescribers such as dental practitioners, podiatrists, and optometrists. All of whom may be involved in the shared decision-making for deprescribing. This guideline is applicable in the various settings where deprescribing decisions may be made including primary care, hospitals, and residential care. It is intended as a practical guidance to help prescribers decide with the individual which regular medicines can be considered for deprescribing. It provides 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, this guideline aims to identify monitoring requirements during the deprescribing process and address ongoing treatment needs as applicable.

This guideline is for deprescribing in older people. While these recommendations are intended for this population, the guideline development team accepted that some guidance may also be applicable to people under 65 years of age. Furthermore, chronological age does not necessarily reflect an individual's health status. The evidence informing the review is for people over the age of 65, and cautious clinical judgement is required in applying the guidance to younger people.

This guideline does not address all medicines available in the market. It is intended to focus on the top 100 commonly dispensed medicines in the Australian Pharmaceutical Benefits Scheme (PBS) for people over 65 years. The guideline development group reviewed and considered the inclusion of less commonly used medicines (not part of the top 100) where evidence for deprescribing is identified in the literature search. Additionally, depending on the available evidence, this guideline may not address all medicines in the same drug class as the common PBS medicines. A limitation of using the PBS data to estimate common medicines is the data does not include medicines available without a prescription, such as over-the-counter and complementary medicines, or medicines dispensed on private prescriptions.

The guideline includes medicines prescribed for regular use and excludes medicines prescribed for short-term, intermittent, as-required, or acute use only (e.g. systemic or topical antibiotics). Where recommendations involve tapering a dose, healthcare professionals are advised to consult relevant resources and available medicine information to determine the most appropriate method for dose adjustment based on the medicine, its formulation, and person-specific factors. This guideline is not intended to be used as a substitute for disease-specific therapeutic guidelines and evidence-based resources related to non-pharmacological strategies for the management of a medical condition.

Under-prescribing is another important aspect of medicine management which occurs when a clinically indicated medicine is not being prescribed for a person. This guideline does not consider appropriate medicines that are not present, or omissions as this is beyond the scope of this guideline. It is likely that, in some cases, clinically indicated medicines may be identified during the deprescribing process. The information provided in this guideline should be considered in the context of an individual's circumstances (including health and financial status), life experience, goals and expectations as well as cultural and personal values and beliefs.

There are two main parts to this guideline. The first section “Polypharmacy/Multiple Drug Classes” can be viewed as the general principles for deprescribing. This section includes evidence on deprescribing without specifically targeting specific drug classes which includes studies targeting polypharmacy, three or more drug classes, or medicines with a certain pharmacological action covering multiple drug classes. Subsequent sections are organised by specific drug classes. Within each section, individual medicines or drug classes are discussed.

Deprescribing is inherently intertwined with and an essential part of good prescribing practice. In each specific drug class section of this guideline, a brief review of relevant guidance for the appropriate use and continuation of medicines is provided. This review is not based on a systematic literature review but incorporates evidence from a non-systematic review of sources including clinical practice guidelines, position statements, and expert consensus documents.

Further details on the recommendation types can be found in the Methodology section. The Summary of Recommendations provides a brief overview, serving as a quick reference to support clinical decision-making. For more information on the evidence review process, refer to the individual drug class sections in the appendices of the Technical Report. The Technical Report documents the methodology, evidence synthesis, and decision-making framework behind the recommendations, including considerations of benefit-risk balance, values and preferences, resource implications, acceptability, and feasibility.