Polypharmacy and Deprescribing: When Less Is More

[HOST] Welcome to ClinicaliQ Clinical Essentials. I'm Emma Hartley, and with me is Dr Anzal Qurbain, pharmaceutical physician. Today we're covering polypharmacy and deprescribing — a topic that's become one of the most important issues in modern prescribing. Dr Qurbain, what's the scale of the problem here?

[EXPERT] In the UK, around 15 percent of emergency hospital admissions in older adults are estimated to be related to medicines — whether that's adverse effects, interactions, or medicines taken inappropriately. Polypharmacy is defined as five or more regular medicines, and roughly half of adults over 65 in the UK meet that threshold. Beyond five, the risk of harm rises significantly with each additional medicine added.

[HOST] Is polypharmacy always bad? I imagine sometimes patients genuinely need a lot of medicines.

[EXPERT] That's a really important distinction. There's appropriate polypharmacy — where multiple medicines are all indicated, evidence-based, and the combination is well-tolerated and contributes meaningfully to the patient's quality of life or longevity. And there's problematic polypharmacy — where medicines are inappropriate, duplicated, interacting, or where the burden of taking them outweighs any realistic benefit for that patient. The goal of deprescribing is to address the second kind while preserving the first.

[HOST] You mentioned a tool called STOPP/START criteria. Can you explain what those are?

[EXPERT] STOPP/START is a validated set of criteria developed in Ireland and widely adopted in the UK. STOPP — Screening Tool of Older Persons' Prescriptions — lists medicines or combinations that are potentially inappropriate in older adults and where stopping should be considered. START — Screening Tool to Alert to Right Treatment — lists medicines that should be considered but may be omitted in certain patients. A good medication review uses both: what to stop, and what might actually be missing.

[HOST] What are the most common deprescribing targets?

[EXPERT] Proton pump inhibitors are probably number one. They get started during a hospital admission, or when an NSAID is prescribed, or for a short-term bout of dyspepsia — and then they continue indefinitely. Many patients have been on a PPI for years with no clear ongoing indication. They're not entirely harmless — long-term PPI use is associated with hypomagnesaemia, vitamin B12 deficiency, increased fracture risk, and possible increased susceptibility to C. difficile.

[HOST] What else is commonly deprescribed?

[EXPERT] Statins in patients with frailty or limited prognosis. The evidence base for statins in primary prevention is based on populations who will live long enough to accumulate the benefit — typically over five to ten years. A patient in their late 80s with dementia and frailty has limited time to accrue that benefit, and the pill burden and potential side effects may outweigh it entirely. Antihypertensives causing orthostatic hypotension and falls in elderly patients is another major target — treating a blood pressure target can be actively harmful if it means the patient falls and fractures their hip.

[HOST] How do you approach the actual process of deprescribing? Patients might be attached to medicines they've taken for years.

[EXPERT] Patients are often more open to stopping than clinicians expect — particularly when the conversation is framed as a positive review rather than a withdrawal. The key steps are: review each medicine's current indication — is there still an active reason for it? Review the evidence of benefit for this specific patient — age, frailty, comorbidities, life expectancy. Identify medicines causing harm or that are no longer appropriate. And then involve the patient fully in the decision.

[HOST] How do you actually stop a medicine safely? Can you just stop them all?

[EXPERT] Not always — some medicines need a slow taper. Antidepressants, particularly SSRIs, should be tapered to avoid discontinuation syndrome. Beta-blockers in heart failure should be tapered, not stopped abruptly. Opioids need a structured reduction plan. PPIs can often be stopped cold, though some patients get rebound acid hypersecretion in the short term. The rule is: if the medicine affects a physiological system the body has adapted to, taper it. If it's more mechanistically straightforward, stopping may be fine.

[HOST] What's a structured medication review in primary care?

[EXPERT] An SMR is a funded activity in primary care in England, commissioned under the Network Contract DES. It's a comprehensive review of all a patient's medicine — indication, efficacy, safety, adherence — ideally with input from a clinical pharmacist embedded in the practice. The idea is that GP practices with embedded pharmacists can systematically identify patients on high-risk medicine combinations or with monitoring gaps, and conduct structured deprescribing conversations.

[HOST] Do patients sometimes ask to stop medicines themselves?

[EXPERT] Yes, and this is a really important conversation to handle well. If a patient says they've stopped taking their statin because they read something online, the right response isn't to simply re-prescribe. It's to explore why, discuss the actual risk picture for them specifically, and either support the decision if the medicine wasn't adding much for them, or have a genuinely informative conversation about why it matters. Unilateral stopping without clinician involvement is also common with antidepressants and antihypertensives — so a regular review where you explicitly ask "are you taking all your medicines, and are you happy with them all?" is genuinely useful.

[HOST] What about older patients who might not raise concerns themselves?

[EXPERT] Older patients often don't want to be a burden or question their doctor. A direct question like "are any of your tablets causing you problems?" or "are there any you're not taking?" often opens up conversations that wouldn't otherwise happen. The Medicines Adherence Consultation skills — developed as part of NICE guidance on medicines adherence — give a framework for these conversations.

[HOST] Is there good evidence that deprescribing improves outcomes?

[EXPERT] The evidence base is growing. There's good evidence that reducing inappropriate medicines in older patients reduces falls, adverse drug events, and hospital admissions. The STOPP/START-guided interventions in randomised trials have shown reductions in adverse drug reactions and falls. It's not quite as headline-grabbing as a trial showing a new drug reduces mortality, but the effect size is real and clinically meaningful, particularly in frail patients.

[HOST] What about patients on complex regimens managed by multiple specialists?

[EXPERT] This is where things get difficult. A cardiologist may add a medicine, a rheumatologist another, and nobody is overseeing the whole picture. The GP is often best placed to do this, but can feel reluctant to deprescribe a medicine started by a specialist. The key principle is that the prescriber responsible for ongoing monitoring and the patient relationship has the standing to initiate a deprescribing conversation — and where uncertain, a letter to the originating specialist asking whether the medicine is still needed is entirely appropriate.

[HOST] What's your clinical pearl for polypharmacy?

[EXPERT] The question I find most useful is: what would happen if we stopped this? For some medicines the answer is obvious — stopping the anticoagulant in atrial fibrillation would substantially increase stroke risk. But for many others — a PPI started six years ago, a statin in a very frail patient, an antihypertensive causing dizziness — the honest answer is "probably not much that's harmful, and possibly something that's beneficial." Making that question part of every routine review changes the conversation from "what do we add?" to "what can we safely remove?" That shift in framing is the heart of deprescribing.

[HOST] That's a great reframe. To summarise: polypharmacy is five or more medicines — it's not always inappropriate but problematic polypharmacy causes 15 percent of older adult admissions. STOPP/START criteria are the framework for reviewing appropriateness. Common deprescribing targets include PPIs, statins in frailty, and antihypertensives causing falls. Deprescribing needs patient involvement and sometimes a taper. And the clinical pearl — ask "what would happen if we stopped this?" and you'll identify a lot of medicines that can safely come off the list. Thank you, Dr Qurbain.

[EXPERT] Thanks, Emma. Prescribing less is sometimes the best prescribing decision you can make.

[HOST] That's all for this episode of ClinicaliQ Clinical Essentials. We'll see you next time.