Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES

Perform a systematic review to evaluate the outcome of deprescription compared with standard care. The focus was on chronic medical and mental health conditions managed in primary care.

DESIGN

The databases searched include PubMed, Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science. Each study was assessed for bias with the Cochrane Collaboration tool.

SETTINGS AND PARTICIPANTS

This review included outpatient, assisted living, nursing home, and acute care settings (if medications for chronic disease were deprescribed). Subjects were non-terminally ill adults 18 years and older.

MEASURES

Primary outcome was successful deprescription, defined as a statistically significant reduction in medication burden between the intervention group and the standard care or control group, or when more than 50% of intervention subjects were able to tolerate medication discontinuation compared with control by the end of the study.

RESULTS

Fifty-eight articles met the study criteria. Thirty-three (58%) had a high risk of bias. Studies varied in duration from 4 weeks to 5 years and were conducted across a diverse array of primary health care settings. The most successful interventions used pharmacist-led educational interventions and patient-specific drug recommendations. Cardiovascular drugs including antihypertensives/diuretics and nitrates were the most successfully deprescribed class of drugs. Psychotropic medications and proton-pump inhibitors were the classes most resistant to deprescribing, despite intense intervention.

CONCLUSIONS/IMPLICATIONS: Deprescription may be successful and effective in select classes of drugs, with collaboration of clinical pharmacists for patient and provider education, and patient-specific drug recommendations, complemented by close clinical follow-up to detect early signs of exacerbation of chronic diseases. This review also suggests that deprescription may (1) require expensive intensive, ongoing interventions by clinical teams; (2) not lead to expected outcomes such as improved falls rate, cognition, and quality of life, or a lower admission rate; and (3) have unexpected adverse outcomes affecting patients' quality of life.