Polypharmacy, deprescribing and medicines optimisation

• Distinguish appropriate from problematic polypharmacy.
• Carry out a structured medicines review linked to indications, goals and patient priorities.
• Identify medicines that may be candidates for dose reduction, withdrawal or simplification.
• Plan deprescribing safely, including monitoring for withdrawal, rebound or disease recurrence.
• Use multidisciplinary review without losing sight of patient preference and clinical accountability.

Medicine count can identify patients who may benefit from review, but a high number of medicines is not automatically inappropriate. A person with multiple evidence-based indications may appropriately need several treatments. The problem is problematic polypharmacy: medicines without a current indication, duplication, excessive risk, interactions, treatment burden, poor alignment with goals or a regimen the patient cannot realistically manage.

A structured review begins with what matters to the patient: symptom control, independence, cognition, falls prevention, avoiding hospital admission, longevity, comfort or reducing treatment workload. The medicines list is then examined against those priorities. This reduces the risk of deprescribing becoming a numerical exercise.

For each medicine ask: What is the indication? Is it still present? Is the medicine achieving its intended benefit? Is there evidence of harm? Is there duplication or interaction? Is the dose still appropriate? Does the patient take it? What happens if it is stopped? Is monitoring complete? Could the regimen be simplified? The result may be continuation, adjustment, replacement, trial withdrawal or deliberate non-change.

Stopping medicines can cause withdrawal, rebound symptoms or recurrence of disease. Some medicines require gradual reduction; others can be stopped directly. The correct method is medicine-specific and should be checked against current guidance. A deprescribing plan should define what will change, what symptoms or measures will be monitored, when review will occur and what would trigger restarting or further adjustment.

Polypharmacy can amplify postural hypotension, sedation, anticholinergic effects, bleeding risk, renal injury and delirium through cumulative effects rather than a single obviously toxic medicine. The review should therefore consider the regimen as a system. Removing one low-value contributor may be safer than adding another medicine to treat the resulting symptom.

In frailty, the balance between long-term prevention and immediate function often changes. The aim is not blanket cessation of preventive treatment but explicit reassessment of benefit, time to benefit, adverse effects, treatment workload and the patient’s priorities. Decisions should be revisited as health status changes.

Communication after review

A medicines review is incomplete if changes are not communicated. Patients and carers should know what has changed and why. Other prescribers should be informed of the rationale, follow-up plan and any medicines that should not be restarted automatically. Clear documentation helps prevent intentional deprescribing from being undone at the next transition.

Sources for this module

• AWTTC: Polypharmacy in older people
• NICE NG5: Medicines optimisation
• GMC prescribing guidance

Educational note: medicine-specific doses, thresholds and rapidly changing regulatory requirements should be checked against current authoritative guidance at the point of care.