Deprescribing Frameworks: How to Cut Medications and Side Effects

When clinicians talk about deprescribing is a systematic process of reviewing and reducing medications that may cause more harm than benefit, especially in older adults, they’re aiming to trim the pill count and lower side‑effect risk.

deprescribing isn’t about stopping drugs on a whim; it’s an evidence‑driven, patient‑centered strategy that balances benefits, harms, life expectancy, and personal goals.

Why Side Effects Drive the Need for Deprescribing

Side effects are the hidden cost of polypharmacy. Studies show that up to 30% of hospital admissions in people over 65 are linked to medication‑related adverse events. Common culprits include dizziness from benzodiazepines, gastrointestinal bleeding from proton‑pump inhibitors, and hypoglycaemia from certain antihyperglycemics. Each unnecessary pill adds a layer of risk, contributes to drug‑drug interactions, and burdens patients with complex dosing schedules.

Core Concepts Behind Deprescribing Frameworks

• Clinical assessment: Review each drug’s current indication, duration, and evidence of benefit.
• Risk‑benefit analysis: Weigh potential harms against the therapeutic goal, considering the patient’s functional status.
• Shared decision‑making: Involve the patient (and caregivers) in setting goals and discussing trade‑offs.
• Tapering & monitoring: Gradually reduce dose where needed and watch for withdrawal or disease recurrence.

These steps are embedded in most published frameworks, from the original Bruyère models to newer AI‑enhanced tools.

Popular Deprescribing Frameworks in Practice

Below are the three most widely adopted structures, each with a distinct workflow.

1. Shed‑MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, Synthesis)

Developed at the University of Toronto, Shed‑MEDS was validated in a 2023 JAMA Internal Medicine trial that cut the average medication count from 11.3 to 9.5 at discharge. The process hinges on a comprehensive medication reconciliation followed by an interdisciplinary team meeting that produces a concise deprescribing plan.

2. STOPP/START Criteria (Version 3, 2021)

The STOPP (Screening Tool of Older Persons’ potentially Inappropriate Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) lists provide explicit red‑flags for over‑prescribing and green‑lights for missing therapies. They are especially useful for identifying high‑risk medications such as long‑acting benzodiazepines or unnecessary PPIs.

3. Deprescribing.org Algorithms

Deprescribing.org hosts step‑by‑step leaflets for five high‑risk drug classes. Each algorithm follows a four‑step pattern: identify eligible patients, confirm indication strength, taper dose, and monitor. The site also offers printable decision aids that integrate easily into electronic health record (EHR) prompts.

Step‑by‑Step Guide to Deprescribing a High‑Risk Medication

1. Identify the candidate: Use the STOPP/START or deprescribing.org list to flag the drug.
2. Gather patient context: Document comorbidities, frailty index, life expectancy, and personal preferences.
3. Assess current benefit: Ask questions like “Is this drug still needed for symptom control?” and review recent lab results.
4. Plan the taper: Follow the evidence‑based schedule for the drug class (e.g., reduce PPIs by 25% every 2 weeks).
5. Educate the patient: Provide written instructions, explain possible withdrawal symptoms, and set realistic expectations.
6. Monitor & adjust: Schedule follow‑up within 1‑2 weeks for high‑risk drugs; use symptom logs or telehealth check‑ins.

Applying this sequence to a 78‑year‑old with chronic heart failure, GERD, and insomnia helped reduce her pill count by three while eliminating nightly heartburn episodes.

Comparison of Deprescribing Protocols for Five Major Drug Classes

Embedding Deprescribing into the Electronic Health Record

Modern EHRs can nudge clinicians automatically. A successful model uses a “hard stop” for high‑risk prescriptions: the system defaults to “no order” unless the prescriber clicks a justification link. In twelve U.S. health systems that piloted this approach (2019‑2021), inappropriate prescribing dropped by 22% and average medication count fell by 1.3 drugs per patient.

Key implementation steps:

1. Map the five high‑risk drug classes to existing order sets.
2. Build rule‑based alerts that reference STOPP/START criteria.
3. Train pharmacists to review alert logs daily and provide recommendations.
4. Set up a feedback loop: clinicians receive quarterly reports on deprescribing impact.

The Multidisciplinary Team: Who Does What?

Evidence shows that pharmacist‑led deprescribing yields 35‑40% higher success rates. A typical team looks like this:

• Physician champion: authorizes the plan, ensures alignment with disease‑specific goals.
• Clinical pharmacist: conducts medication reconciliation, applies algorithms, monitors lab values.
• Nurse practitioner or RN: educates the patient, tracks withdrawal symptoms, documents outcomes.
• IT specialist: configures EHR alerts, extracts data for audit.

In a Canadian study, adding a pharmacist on a 0.5 FTE basis saved $3.20 for every $1 spent through reduced admissions and drug costs.

Measuring Success: Metrics That Matter

When you report back to leadership, focus on these hard numbers:

• Average reduction in medication count per patient (target ≥ 1.5).
• Rate of adverse drug events before vs. after deprescribing.
• Patient‑reported satisfaction with pill burden.
• Readmission rates for medication‑related causes.
• Cost avoidance calculated from avoided hospital stays.

For example, a Midwest health system saw a 12% dip in 30‑day readmissions after implementing Shed‑MEDS across its post‑acute units.

Common Pitfalls and How to Avoid Them

• Time pressure: Break the review into two short visits rather than one long appointment.
• Lack of patient buy‑in: Use visual pill‑counts and simple analogies (e.g., “removing one pill is like taking a lighter bag on a hike”).
• Ignoring comorbidities: Cross‑check each drug against the patient’s full disease list; avoid stopping a med that controls a life‑threatening condition.
• Inadequate follow‑up: Schedule a check‑in call 48‑72 hours after a taper starts.

Quick‑Start Checklist for Your First Deprescribing Cycle

• ✅ Pull the latest STOPP/START v3 list.
• ✅ Identify top 3 high‑risk drug classes in your patient panel.
• ✅ Assign a pharmacist to lead the medication reconciliation.
• ✅ Build an EHR alert for the chosen classes.
• ✅ Conduct a shared decision‑making session with the patient.
• ✅ Document taper plan and schedule follow‑up.

Future Outlook: Deprescribing as a Routine Vital Sign

Regulators are catching up. CMS will add deprescribing metrics to the Merit‑Based Incentive Payment System in 2026, and the European Union’s Pharmaceutical Strategy has earmarked funding for AI‑driven deprescribing tools. By 2030, experts predict that a medication review will be as automatic as measuring blood pressure during an annual wellness visit.

Frequently Asked Questions