Deprescribing: Tapering off meds

By Alan Koenigsberg, M.D.

We physicians receive a substantial degree of training in evaluating, diagnosing and treating patients. That treatment is often a prescription medication, for which we also receive intense training, both during the latter years of medical school and throughout residency training.

If my training is representative, however, we don’t receive much training in tapering patients down and sometimes off, medication treatment.

For many illnesses, diseases and conditions, lifetime treatment is appropriate. Type 1 diabetes, multiple sclerosis, schizophrenia, congestive heart failure and many other illnesses may require and benefit from lifetime treatment.

Given that most registration trials for new medications request volunteers who are generally young adults, there are few trials of older adults that clearly show medication treatment is beneficial and required.

Again, for some conditions, it’s obvious that long-term treatment is needed. A recent New England Journal of Medicine article described several illnesses for which solid evidence of the benefit of long-term medication treatment is scant.

One example they cite is seizures. We know that sudden onset of seizures benefits from medication treatment. The general recommendation is one year of medication treatment with no seizures. What happens next, however, is extremely variable.

We know we don’t want to risk someone driving and having a seizure, so the decision to taper and stop antiseizure medications is a serious one that requires considerable deliberation but may be appropriate.

For others, I have personally and professionally experienced older people taking blood pressure medications that contribute to their falling. While the standard “normal” blood pressure is considered to be 120/80, again, that determination had been made decades ago, with a healthy, 30-something male being the gold standard.

However, we know that as we age, atherosclerosis, or hardening of the arteries, occurs in most of us. This means that a higher blood pressure is needed to push our blood through our arteries. Again, this means that when we are in our 70s and 80s, a “normal” blood pressure of 120/80 may very well be so low that we pass out from low blood pressure and fracture a hip.

So, while we don’t want high blood pressure to increase the risk of having a stroke, we also don’t want relative low blood pressure increasing the risk of a fall and fracture.

Then there are medications to lower cholesterol. Are they needed in our 70s and 80s? I’m not sure we know conclusively.

Just as we have recently rethought prescribing opioids casually, we may want to reconsider continuing all of our patients’ chronic medications, just because we have been doing so.

Many patients may indeed want to continue taking their medications for the comfort and peace of mind they provide and that may be a valid rationale.

My point here is that as we age, there is a tendency to take more medications, not just briefly or for a few weeks, but chronically and more or less forever.

Sometimes and maybe often, that can be justified. Sometimes, however, it is necessary to discuss with one’s internist or family physician about each and every medication, the pros and cons and especially the doses.

Lastly, please ask about drug interactions, as well as potential side effects with over-the-counter medications such as antacids and herbal drugs.

Just because you have been taking a medication since you were 30 doesn’t necessarily mean you need to take it when you’re 70 or 80.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at akoenigsberg@mac.com.

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