Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Australia2School of Medicine, University of Queensland, Brisbane, Australia.
Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, Australia4Kolling Institute of Medical Research, School of Medicine, University of Sydney, Sydney, Australia.
JAMA Intern Med. 2015 May;175(5):827-34. doi: 10.1001/jamainternmed.2015.0324.
Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies. A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one; (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application.
不适当的多种药物治疗，特别是在老年人中，会造成严重的药物不良反应、健康不良、残疾、住院治疗，甚至死亡。预测老年人不适当处方和药物不良反应风险的最重要单一因素是处方药物的数量。逐渐减少药物剂量或停药是指减少多种药物治疗，以改善患者的预后。从随机试验和观察性研究中出现了逐渐减少药物剂量的疗效证据。提出了一个逐渐减少药物剂量的方案，包括 5 个步骤：（1）确定患者目前正在服用的所有药物及其每种药物的原因；（2）根据药物引起的伤害风险，确定药物减少干预的必要强度；（3）评估每个药物的当前或未来的获益潜力与当前或未来的伤害或负担潜力；（4）优先考虑停药的药物，这些药物具有最低的获益-危害比，以及最低的不良反应停药反应或疾病反弹综合征的可能性；（5）实施停药方案，并密切监测患者的结果改善或不良反应的发生。虽然存在患者和处方者对逐渐减少药物剂量的障碍，但有可用的资源和策略可以促进深思熟虑但明智的逐渐减少药物剂量，值得更广泛的应用。
