Clinical guidelines tells doctors how prescribe drugs, but not when to stop them

Clinical guidelines in medicine are failing to provide doctors with adequate information on how to stop or reduce the dosage of medicines that may be harmful or unnecessary.

Medications are sometimes harmful or unnecessary and should be reviewed.

Clinical guidelines in medicine are failing to provide doctors with adequate information on how to stop or reduce the dosage of medicines that may be harmful or unnecessary, amid growing concern over high rates of inappropriate prescribing of drugs such as antidepressants. 

The largest international review of deprescribing recommendations in medicine found only 29 per cent of clinical guidelines mention deprescribing, and less than 10 per cent provide guidance on exactly how medication dosages should be ceased or reduced.

Australian researchers from Monash University led the study, published in the British Medical Journal Quality and Safety, which found insufficient deprescribing recommendations were a universal trend, with the review’s findings highlighting a glaring omission in clinical practice guidelines internationally.

Deprescribing means medication dose reduction or cessation, and is an integral component of appropriate prescribing. The risk of not having clear guidelines as to how to taper down or cease medication is clear in the case of medicines that have been widely overused and can be addictive, such as opioids or benzodiazepines. Recently, attention has shifted to very widely used medications such as SSRIs and the extreme difficulty some patients find when attempting to cease the medications, with powerful withdrawal symptoms and myriad side-effects. Many patients have not received appropriate advice on dose reduction because of insufficient focus on deprescribing in clinical guidelines. One in seven Australians is taking an SSRI medication daily.

The issue prompted psychiatrists to author a special edition of the world’s foremost prescribing guide, the Maudsley Guidelines, focused on deprescribing such medications. Australia’s Royal College of General Practitioners is considering endorsing the Maudsley Guidelines on deprescribing.

Clinical practice guidelines contain recommendations on how health practitioners should both diagnose and treat medical conditions, as well as prescribe medicines.

In the study, led by the Centre for Medicine Use and Safety within the Monash Institute of Pharmaceutical Sciences, 2866 clinical guidelines published internationally from January 2012 to November 2022 were analysed. The researchers found 71 per cent did not contain any guidance on deprescribing and, of the 80 guidelines found to include deprescribing recommendations, most did not have detailed information setting out how to deprescribe.

Research fellow Aili Langford. Picture: X

CMUS research fellow Aili Langford, co-lead author of the BMJ study, said that was concerning in the not uncommon situation where the harms of a medicine may outweigh the benefits.

“I think part of the issue is that perhaps sometimes there isn’t good evidence about when or how to deprescribe these types of medicines,” Dr Langford said. “What stood out is the need for greater clarity and specificity in … recommendations. If recommendations are unclear, they are unlikely to be implemented as intended.

“The potential benefits and harms of medicines can change over time as a person ages, acquires new medical conditions, takes new medicines and changes their care goals. Therefore, medicines should be regularly reviewed to make sure they are still of benefit, and not causing harm.”

In Australia, around 400,000 people present to emergency departments each year because of medication-related problems, with at least 50 per cent of this harm deemed preventable. It’s an even bigger issue in the elderly.

Dr Emily Reeve. Picture: Supplied

Emily Reeve, senior author of the study and chair of the Australian Deprescribing Network, said overprescribing was a major problem here and internationally.

“We essentially know that deprescribing is not happening as often in practice as it should be,” Dr Reeve said. “And particularly, that speaks to the use of what we call inappropriate medications.

“We certainly always say that we are not anti-medication, it is not about stopping all drugs and it’s not about saving costs. It’s not about any of those things, it is about providing best care.”