Deprescribing preventive medication in older patients

I was delighted with the prominence given in your October issue to the role of clinical pharmacists in general practice. It was pleasing to see at last evidence that their work in medication management can free up GP time, a precious commodity when recruitment is in the doldrums.¹ I suspect they will do it more effectively too.

I am concerned, however, that you have joined the deprescribing bandwagon.² While it is good to see evidence that deprescribing seems to be safe,³ the emphasis on this fashionable almost mechanical tool in therapeutics detracts from the holism that should be the mature approach of health professionals, be they doctors, nurses or pharmacists. It is further worrying that NHS managers may see this a cost cutting tool and encourage its use as a one-off intervention.

When clinical pharmacists first worked in primary care, their approach tended to be cautious and algorhythmic. This probably related to the technical nature of pharmacist training in the past, and the need to establish themselves in a new and sometimes suspicious environment. But today’s pharmacists have learned interpersonal skills, gained confidence and can look at the patient as a whole. To send them out to do one isolated task is retrogressive. They must look at the patient, the illnesses and the treatment as a whole. Stopping the odd tablet here and there may divert them from seeing that the patient isn’t taking the pills properly anyway. Patients change: they get older and sometimes forgetful, they develop new disease, they get fatter or thinner, their lifestyle and life situation alter, their attitudes and views change, including those towards illness and its treatment. Illnesses change: they progress, but sometimes they get better. They interact with each other. New ones develop. Therapeutics changes: There are newer drugs, newly identified adverse effects and interactions and evidence of benefit or harm. Without looking at the whole picture the clinician (whether doctor or pharmacist) is underusing skills and short-changing the patient. So let us encourage a whole patient approach to therapeutic care, using tools, but only as part of a broader approach to maximising the patient’s health and well-being.