The American Heart Association has outlined the four types of patients who may benefit from deprescribing of medications for cardiovascular disease, giving clinicians a blueprint for managing the risks while minimising adverse events.

The association’s statement on deprescribing for patients with CVD experiencing polypharmacy compiles the most recent evidence on deprescribing practices, arguing specialists should start by identifying patients most likely to benefit from reducing their overall number of medications [link here].

. These include:

• Those with a history of adverse drug events: treating doctors should be cautious to avoid attributing nonspecific symptoms to ageing and consider the possibility of a patient’s medications leading to symptoms. “Patients with a history of falls—particularly recurrent falls—deserve special consideration because falls may reflect underlying ADEs and are associated with substantial morbidity and mortality,” the statement said,
• Patients with polypharmacy: where more than one of their prescriptions is either no longer indicated, not providing any current benefit or no longer aligning with their long-term goals,
• Patients with ‘prescribing cascades’: where new or worsening symptoms emerge after initiation of a new therapy, and
• Those in palliative care or end of life settings: “in whom goals of care typically shift toward managing symptoms and minimizing treatment burden”, the statement argued.

Once a patient has been identified as a candidate for deprescribing, clinicians should take a structured approach to identifying which medications should stop and why.

Here they can draw on another four-step approach, the AHA said, working through verification, identification, reconciliation and communication.

Verification involves gathering a medical history from multiple sources including GPs, pharmacists and the patient to ensure a full record of prescriptions is available. From here, the list can be reviewed for any discrepancies or issues, before the doctor works with the rest of the treating team to reconcile which therapies are necessary.

Finally, an update on medications must be shared across the patient’s care team.

“Systematic medication reconciliation conducted regularly, particularly during high-risk periods such as transitions of care, can help identify PIMs, ensure congruence between medications and goals of care, and improve adherence and quality of life,” the association said.

There are many deprescribing strategies and guidelines across jurisdictions, but the AHA identified a few key principles to simplify whichever process is used.

Key action items for doctors included:

• All cardiovascular specialists should identify polypharmacy as a potential problem for patients,
• Specialists should review patients for adverse events, polypharmacy, prescribing cascades and palliation and use these instances as a time to review medications,
• Patients should be involved in shared decision making about which medications are ceased,
• Any decisions must be communicated across the entire care team, to work out a deprescribing plan.

The statement noted that clinician inertia and a fear of negative consequences were barriers to stopping a therapy.

Meanwhile, the current literature on deprescribing had several shortcomings, and more rigorous RCTs were needed to establish the best tapering approach for a therapy.

Despite these limits, deprescribing should be considered a key part of optimal prescribing practices for all patients with CVD, the association said.

“Deprescribing programs should leverage the availability and expertise of all team members, including physicians and nonphysicians, to overcome existing barriers,” they said.