Once upon a time, a doctor needed a pen and prescription pad to provide a patient a new medication. Horrible handwriting often made such prescriptions hard for pharmacists to translate. Now, a few keystrokes on a computer sends the prescription to a local pharmacy or a mail-order organization. And once you receive a new medication for type 2 diabetes, high cholesterol or diabetes, there is a strong likelihood that you will be on it for months, years or even decades. If someone suggests cutting back on a medicine, many health care professionals adopt a mantra: “don’t mess with success.” But more and more experts are starting to recommend “deprescribing” to help patients get off nonessential drugs, especially as they get older.
JAMA Article: “Deciding When It’s Better to Deprescribe Medicines Than to Continue Them”
The American Medical Association (AMA) was founded in 1847. Membership exceeds 250,000 doctors. JAMA, aka The Journal of the American Medical Association, has been around since 1883.
The 13 peer-reviewed journals under the JAMA umbrella are described as:
“…the authoritative source for cutting-edge research, informative review and thought-provoking opinion across medical specialties.”
That is why we were impressed by the title of the article mentioned in the headline above (JAMA, Nov. 29, 2023).
It starts this way:
“Seasons change, fashions change, US presidents change, but for many patients, prescriptions never do—except to become more numerous.”
In this article a Kaiser Permanente geriatrician, Dr. Eric Lee, remarks:
“We’re all taught how to prescribe these medications. We’re not taught how to stop these medications.”
As a result, more than one-fifth of American adults (especially people over 60) take at least five different prescription medicines in the course of a month. Many people take a lot more pills, especially if you add in OTC drugs and dietary supplements.
Why So Many Medicines?
A handful of pills might not be a problem if drugs had no side effects. But prescription medicines can cause a range of problems. On an average day, 750 older adults are hospitalized with adverse drug effects.
Drug commercials make modern medicines seem like miracles. They feature people having a wonderful time sailing boats, dancing, swimming, climbing walls or riding motorcycles despite serious health problems such as rheumatoid arthritis, ulcerative colitis, psoriatic arthritis, depression or eczema.
Many healthcare consultations finish with a prescription. Busy doctors may find it helpful to bring the visit to a close. And patients have come to expect it. They may feel cheated if they don’t receive a prescription. In that moment, no one is thinking about how to stop the medicine.
Who Teaches Health Professionals How To Deprescribe?
Doctors, nurses and other prescribers don’t usually learn much about discontinuing drugs. Even pharmacists may not know how to do this. As a result, deprescribing is a relatively new concept. Neither the FDA nor drug companies have made it a priority.
Because drug companies have no incentive to help doctors deprescribe, there are no good guidelines for stopping most medicines. The human body often adapts to the presence of a drug. Stopping it suddenly can throw the system out of balance.
Most people know that you can’t quit an opioid too abruptly, or there will be terrible withdrawal symptoms. Fewer know that other drugs for pain relief, such as gabapentin or pregabalin, can also be very tough to stop.
One reader described his struggle to get off pregabalin:
“Things went fine when I went down to 100 mg daily, taking 50 mg twice a day. Now I have gone to 75 mg once a day and I feel horrible. I can’t sleep, and if I do, I have weird dreams. I feel foggy, angry and easily irritated. Still, I will press on, no turning back now. I expect two more weeks like this, then I’ll go down to 50 mg a day. My wife says I am having withdrawal and I know she is right.”
There are many other types of medicines that can cause withdrawal symptoms (or what the FDA calls “discontinuation syndrome”). Benzodiazepines like alprazolam (Xanax) or lorazepam (Ativan) are notorious in this regard. But many people don’t realize how hard it can be to stop an antidepressant or an acid-suppressing PPI.
Health care providers are beginning to consider other options to help people get off pills that are causing trouble. Sometimes nonpharmaceutical approaches, such as cognitive behavioral therapy, are helpful. At other times, a lower dose or a different type of medicine may be needed. The new focus on deprescribing is long overdue.
Does Deprescribing Help Reduce Problems?
Older people, in particular, frequently end up taking a number of prescription and over-the-counter medications. As they accumulate conditions, they may also add to the number of drugs they are taking. This in turn increases the risk for side effects or interactions.
A group of researchers at Vanderbilt University Medical Center recruited older patients on five or more drugs between 2016 and 2020 (JAMA Internal Medicine, Feb. 6, 2023). As the patients left the hospital for a rehab facility, the scientists randomly assigned them to patient-centered deprescribing or control.
Patient-Centered Deprescribing:
Pharmacists and nurse practitioners reviewed patient charts and interviewed the patients to identify medicines that the patient might be willing and able to do without. They recommended action and monitored prescriptions after the patients transferred to the post-acute care facility.
Comparison with the control group showed this intervention was safe and effective. It resulted in a significant reduction in the number of medications that patients were taking once they got home. Most importantly, they were taking fewer potentially inappropriate medications. Reducing the number of drugs did not trigger adverse events, hospitalizations or increased deaths.
Can Too Many Pills Cause Dangerous Ills?
America is a nation of pill takers. At last count we spent over $400 billion on more than 4 billion prescriptions.
If you assume that a typical prescription bottle has 30 pills, the total comes to 120 billion capsules or tablets each year. That’s more than one pill a day for every man, woman and child and does not include OTC medications.
Many children and young adults don’t take any medicine. That’s because most are healthy and do not need drugs for high blood pressure, elevated cholesterol or sluggish thyroid function. Older people, on the other hand, may take a handful. Are all these medicines essential for good health?
More Pills to Treat Drug Side Effects:
Sometimes after starting a medication, the patient might discover that it causes an unpleasant side effect. If the person complains to the doctor, the response might be an additional prescription to manage that side effect. Occasionally the patient gets caught in a prescribing cascade that ends with him taking several more medicines than he started with, just to counteract the side effects.
We heard from one reader:
“I took meloxicam for pain and inflammation, but it caused a perforated ulcer. My doctor prescribed Nexium for several years because of the ulcer.
“Stopping Nexium was challenging. It took me six months of gradually reducing the dose to get off it.”
The Problem With Prolonged PPI Use:
Nexium and other acid-suppressing drugs such as Prilosec or Prevacid may themselves cause complications such as infections, kidney damage, nutrient deficiencies and fractures.
If a person falls and fractures a hip after years on a PPI acid-suppressing drug, no one would think the heartburn medicine could have contributed. Ditto for kidney damage. Many health professionals might say “bad luck,” or “bad genes,” or just blame the problem on “too many birthdays.”
Overprescribing Is Not Uncommon:
Another reader shared this story about overprescribing:
“My late mother-in-law was on numerous medications, and the number was growing as she developed new ailments. Unbeknownst to her children, she had gone through her entire savings and had begun selling off family heirlooms to pay for all of her medications.
“She got a new doctor who discontinued about half of her prescriptions. My mother-in-law felt dramatically better and could now afford her prescriptions.
“So the poor woman spent her entire savings and then some on meds that only made her feel worse. Grrr!”
Statins and Blood Sugar:
We have heard from many people that statins can raise blood sugar. That in turn leads to a prescription for diabetes drugs. Here are a couple of stories from visitors to this website:
Elaine in Buffalo, New York shares this experience:
“After years of taking statins, my blood sugar and glucose levels are high enough that my doctors say I’m a Type 2 diabetic. They wanted me to go on metfomin which I strongly declined because of the side effects. There is no history of diabetes in my family and I’m completely convinced that it’s the statins that caused it. I’ve gone from 10 mg of Crestor to 5 mg and am hoping to be able to get off that.”
Greg in North Carolina had a similar story:
“My doctor prescribed atorvastatin to reduce my cholesterol levels which were borderline. My A1c [hemoglobin A1c is a measure of blood glucose over time] levels were 4.8 before I took the statin. I exercise daily (3 mile runs) and I’m not overweight.
“When I came back to get my liver enzyme level checked (6 months after starting the statin), I’m now pre diabetic with a 6.1 A1c level. I have stopped taking the statin and I hope my A1c drops.
“My doctor was getting ready to prescribe a medication to lower the A1c but I said wait. I get weary of the what I call the prescription drug treadmill where your doctors starts to prescribe medications to treat problems from other medications.”
Deprescribing: Cutting Back On Nonessential Drugs:
When people start taking medicines to treat side effects of other medicines, the drug treadmill can indeed become overwhelming. That’s why some physicians are reconsidering the medication merry-go-round. Experts call it deprescribing. This means determining which medicines might not be essential and helping patients discontinue them safely.
One reader described a successful experience with deprescribing:
“My husband was taking many medications and sustained a series of falls in April and May 2016. While he was in a rehab hospital, I checked his prescription drugs on the Internet to find out the side effects of each medicine. Of the drugs he was taking, at least seven could cause dizziness as a side effect.
“When he came home after a visit to his primary care doctor, I stopped all his medicines, except for his high blood pressure pill. I asked the doctor first. I also requested a blood test for vitamin B1.
“The results showed he was low in B1, an essential vitamin that helps brain function. My husband started taking it and has not had a fall or been dizzy since stopping all those prescriptions.”
Dizziness is one of those side effects that health professionals often overlook. That’s because it is so hard to treat. Dizziness is incredibly disruptive. It makes you feel bad. Far worse, it can lead to a fall. When an older person falls it can lead to a fracture. That can be a life-threatening event. Many people do not survive after a hip fracture. If one or more medicines cause dizziness, it is time for a physician to consider deprescribing.
Deprescribing Requires Expertise:
This website has become a beacon for people experiencing adverse reactions when they stop certain medicines. Here are just a few examples of what can happen if a drug is stopped too suddenly:
Peggy in Florida recounts her experience with a benzo:
“Benzodiazipine deprescribing: I took Klonopin (clonazepam) for 20 years for insomnia, as much as 4 mg per night. I started to taper off slowly and this took over two years. Despite this effort, I went into a severe withdrawal with physical symptoms: burning, stinging, heat, spasms, nerve pain, paresthesias, intense spaciness, dizziness, memory problems, nausea/loose bowels, constipation, weight loss, and others.
“Much of this has greatly decreased after 19 months post last dose and I have gained 15 pounds. But symptoms still keep me up at night, mainly paresthesia, and bother me during the day. Slowly I am recovering from this terrible ordeal. I take no prescriptions because I have a very supportive doctor. My age is now 70.
“Also- I just had a genetic test at a university teaching hospital. I have a metabolic gene variation that accounts for why my drug withdrawal was so bad.”
Many people experience withdrawal symptoms when they stop taking a benzodiazepine suddenly. These are drugs like alprazolam (Xanax), chlorazepate (Tranxene), chlordiazepoxide (Librium), clonazepam (Klonopin), lorazepam (Ativan), flurazepam (Dalmane), oxazepam (Serax), prazepam (Centrax), temazepam (Restoril) and triazolam (Halcion). Withdrawal symptoms may include:
Anxiety, agitation, restlessness, irritability, inability to concentrate, panic, insomnia, forgetfulness, depression, headache, muscle twitches, muscle cramps, tiredness, sweating, seizures, diarrhea, visual disturbances and nerve sensitivity (paresthesias).
Carol in Tennessee shares a statin story:
“My mother is now 91 and in a nursing home with dementia, lack of mobility, and is incontinent. Due to high cholesterol, she had been taking statins for close to 40 years.
“She had a severe UTI [urinary tract infection] which accelerated her dementia and move to the nursing home. With the prospect of only a few months left, I made the decision to spare her the blood draws and liver checks which went along with the statins.
“That was a year and a half ago. She still has memory loss and struggles with speech, but her personality has returned. Her confusion has diminished. She is happy and enjoys her food and birds and flowers and visitors. She has shown no signs of heart problems. For us, it was a good decision.”
Never Stop ANY Medicine Suddenly on Your Own!
We caution that no one should ever stop medicines without medical supervision. Withdrawal symptoms are surprisingly common for a great many medications. We have developed a special section of our website devoted exclusively to Drug Withdrawal. When you go to this link you will learn about dozens of medications that can cause severe complications if stopped suddenly. Here are just a few of the drugs you will find in this section along with strategies visitors to our website have developed with their health care professionals for gradual tapering:
- Cetirizine (Zyrtec)
- Desvenlafaxine (Pristiq)
- Citalopram (Celexa)
- Duloxetine (Cymbalta)
- Esomeprazole (Nexium)
- Lansoprazole (Prevacid)
- Omeprazole (Prilosec)
- Pregabalin (Lyrica)
- Sertraline (Zoloft)
- Tramadol (Ultra)
- Venlafaxine (Effexor)
Listen to our Radio Show on Deprescribing!
Deprescribing could be dangerous unless it is overseen by an expert in drug actions and interactions. Geriatricians (specialists in treating older people) are well qualified to evaluate patients who may be overmedicated. To help with that process, we offer our free Drug Safety Questionnaire, available at PeoplesPharmacy.com. We also recommend our Guide to Drugs and Older People with more information on drugs that should rarely, if ever, be taken by senior citizens.
You will also want to listen to our radio show with two experts on deprescribing. You can listen to the free audio stream on your computer or download the mp3 file. This one-hour radio show could be shared with physicians and other prescribers who would like to learn more about phasing out non-essential medications. More recently we spoke with Dr. DeLon Canberbury (PharmD, BCGP). He is the founder and president of GeriatRx. Learn about this consulting service and why it is important at this link. You can listen to the podcast at this link.
Always seek the help of a pharmacist if you have any questions about how to gradually stop a medication. They can help monitor your progress and provide essential follow-up!
Please share your own story in the comment section below.
