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

Abstract

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.

Keywords: Deprescription; medication burden; polypharmacy; potentially inappropriate medications; systematic review.