Introduction
Worldwide, our populations are living longer, but with a greater burden
of health conditions. The presence of multiple conditions (i.e.
multimorbidity) drives prescribing of medications, and many people, in
particular older adults, are on multiple medications (or
polypharmacy).(1) Medications are often continued when they are no
longer needed or pose a greater risk of harm than benefit. Such
potentially inappropriate prescribing can impact quality of life, cause
adverse drug reactions, consume healthcare resources, and increase
mortality.(1)
Deprescribing, the process of stopping or reducing such medications, is
one important way to address this.(2) Deprescribing interventions focus
on actions to reduce the number of medications, congruent with the
historical view that polypharmacy is inappropriate and increases risk of
harm. However, there is increasing recognition that the number of
medicines itself is not harmful, as having multiple long-term conditions
may need multiple medicines. Therefore, improving the appropriateness of
polypharmacy through medicines optimisation may involve starting or
increasing medicines as well as stopping in many circumstances.(3)
Deprescribing can be considered as one important component of medicines
optimisation. Given the many barriers to deprescribing and limited
implementation in routine practice, it is understandable that
significant attention is given to assessment of deprescribing
interventions as a high priority.(2)
There is substantial heterogeneity among trials which evaluate
deprescribing, as many interventions also combine deprescribing with
other actions to promote appropriate polypharmacy.(3) There can be
variation in the study designs used (e.g. randomised trials, controlled
before and after studies), as well as important differences in the
intervention target (focused on one medication or many) and the scope of
the intervention (solely deprescribing, or also including other aspects
of medicines optimisation in addition to deprescribing).
In developing and evaluating deprescribing interventions, the decisions
regarding the intervention target and scope are critical. Here, we
reflect on how these decisions (one versus many medications, and
deprescribing versus medicines optimisation) can affect other study
design considerations, specifically developing interventions and
measuring outcomes.