Author + information
- Ashok Krishnaswami, MD, MASa,b,∗ (, )@cardskrish@KPSanJose,
- Michael A. Steinman, MDc,d,
- Parag Goyal, MD, MSce,
- Andrew R. Zullo, PharmD, PhDf,g,
- Timothy S. Anderson, MDh,
- Kim K. Birtcher, PharmD, MSi,
- Sarah J. Goodlin, MDj,k,
- Mathew S. Maurer, MDl,
- Karen P. Alexander, MDm,
- Michael W. Rich, MDn,
- Jennifer Tjia, MD, MSCEo,
- Geriatric Cardiology Section Leadership Council, American College of Cardiology
- aDivision of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California
- bDepartment of Epidemiology and Biostatistics, University of California, San Francisco, California
- cDivision of Geriatrics, University of California, San Francisco, California
- dDivision of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, California
- eDivision of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
- fDepartments of Health Services, Policy, Practice and Epidemiology, Brown University School of Public Health, Providence, Rhode Island
- gCenter of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- hDivision of General Internal Medicine, University of California, San Francisco, California
- iUniversity of Houston College of Pharmacy, Houston, Texas
- jGeriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon
- kDepartment of Medicine, Oregon Health and Sciences University, Portland, Oregon
- lDivision of Cardiology, Columbia University Medical Center, New York, New York
- mDivision of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- nCardiovascular Division, Washington University, St. Louis, Missouri
- oDepartment of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
- ↵∗Address for correspondence:
Dr. Ashok Krishnaswami, Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California 95119.
• Multimorbid older adults with CVD are disproportionately affected by medication-related issues.
• Deprescribing is an integral component of good prescribing practice.
• Incorporating deprescribing into routine cardiovascular care can reduce treatment burden and morbidity in older adults.
Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction—a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced. Using a framework to deprescribe, this review addresses the rationale, evidence, and strategies for deprescribing cardiovascular and some noncardiovascular medications.
The aims of drug therapy are to forestall or treat disease, improve quality of life, and increase longevity. Balancing those central aims are the associated risks and burdens of drug therapy—particularly common in multimorbid older adults with cardiovascular disease(s) and geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction. Furthermore, the limited inclusion of older adults in clinical trials (1), known heterogeneity in treatment efficacy and safety (2), and an evolutionary shift toward a less-is-more attitude regarding medication use (3) has prompted a need to re-examine the balance between benefits and risks at the level of the individual patient. However, this requires assessments in areas other than the medical/surgical domain, such as patients’ values and goals of care, cognitive and physical function, multimorbidity, and medication burden (4). Although further developed in other countries, this re-equilibration of medication use is gathering momentum in the United States under the auspices of an emerging focus called “deprescribing,” most relevant to older adults but applicable across the lifespan (5).
Deprescribing, a top priority in patient safety (6), is the process of medication withdrawal or dose reduction under health care supervision to reduce unnecessary or potentially harmful medication use with the goal of improving outcomes (5,7). The primary aim of this review is to communicate fundamental concepts of medication deprescribing to the cardiovascular clinical team (cardiovascular physicians, pharmacists, nurses, nurse practitioners, physician assistants) (8). Bridging the knowledge gap will lead to more meaningful collaborations between the cardiovascular team and clinical partners (primary care, geriatrics, palliative care) and will advance the view that discussions surrounding deprescribing are considered an integral component of routine cardiovascular care.
Definition of Deprescribing
Common definitions of deprescribing have included in their description a process of medication removal or dose reduction (5,7,9). A notable key feature of a proactive approach to deprescribing is the explicit focus on the relative benefits and harms. These are tied to a holistic review of a patient’s medication list, clinical situation, and life circumstances. Therefore, a comprehensive definition of deprescribing should include: 1) an organized process of medication removal or dose reduction; 2) oversight of the deprescribing process by an appropriate member of the health care team; 3) a goal of improving 1 or more specific outcomes; and 4) consideration of an individual’s overall physiological status, stage of life, and goals of care. This can apply both to a broad-based review of a patient’s medications to identify potential candidates for deprescribing, and to a specific focus on one class of medications.
Rationale for Deprescribing
Most clinical practice guidelines (including cardiovascular guidelines), along with the evidence-base from which they are derived, have either incompletely addressed or omitted addressing care of older adults with multiple chronic conditions or multimorbidity. The presence of multimorbidity, in addition to the index cardiovascular disease (CVD), enhances the difficulty of disease-based care. This is due in part to competing risks (2) and recommendations (e.g., therapeutic competition between guidelines or increased risk for adverse events due to coexisting illnesses) that render assessments of efficacy and safety of pharmacological therapies difficult.
Guidelines have greatly aided the standardization of care. They have even addressed concerns of medical undertreatment (10). However, strict guideline adherence in older adults have had unintended consequences—increased medication burden often leading to decreased functional capacity and quality of life (11). Proposed mechanisms include the direct action of individual agents, worsening polypharmacy (increasing the possibility of interactions between medications, diseases, and patients), and increased treatment burden (12,13). Guidelines additionally do not consider the potential for competing recommendations across conditions, known as “therapeutic competition” (e.g., nonsteroidal anti-inflammatory agents for arthritis, which can worsen hypertension, coronary artery disease, or heart failure) (14).
Current cardiovascular guidelines rarely discuss treatment duration for cardiovascular pharmacological therapies. Some medications are appropriately time-limited (e.g., antiplatelet agents such as clopidogrel, prasugrel, or ticagrelor post-coronary stent implantation). However, many cardiovascular medications do not have a time limitation and are routinely administered over many years. Rossello et al. (15) noted the lack of long-term (≥10 years) efficacy and safety data for commonly used cardiovascular medications. In fact, the average duration of follow-up in 30 secondary prevention trials examining 4 core cardiovascular medications (i.e., aspirin, beta-blockers, statins, and angiotensin-converting enzyme inhibitors) was around 3 years. Because long-term benefits and risks of many cardiovascular medications are unknown, especially in older adults with multimorbidity, medication appropriateness should be tailored and determined within the context of each patient’s clinical milieu, function, life expectancy, health priorities, and outcome goals (16,17).
Ethical Basis for Deprescribing
Acts of prescribing and deprescribing can be considered in the context of 4 ethical principles: beneficence, nonmalfeasance, autonomy, and justice. These principles may be helpful when the appropriateness of deprescribing is unclear. Beneficence refers to how clinicians should act in the best interest of the patient, typically by determining whether an intervention can fulfill the goals of medicine by providing benefit such as symptom control. Nonmalfeasance (“first, do no harm”) means that clinicians must evaluate potential medication risks in relation to potential benefits. Although typically understood as adverse side effects, harms also include burden related to administration and/or cost. Autonomy, considered as individual self-determination in defining preferences for treatment and desired health outcomes, is key. Incorporating patients’ health care beliefs, values, and goals for care, particularly as they may change over time, is essential. Justice, the ethical principle governing the fair and equitable distribution of burdens and benefits to all members of society, is an important consideration with regard to the economic cost of inappropriate, nonbeneficial, or potentially harmful medications, including the cost of harm associated with their use. Deprescribing is concordant with these ethical principles when serving patient-centered interests (18).
Triggers to Deprescribe
There are numerous clinical scenarios where the cardiovascular clinical team should consider deprescribing. Based on current evidence, we grouped common triggers to deprescribe into 4 easily recognizable categories.
Adverse drug reactions
Adverse drug reactions (ADRs) commonly occur in older adults and are often underdiagnosed. ADRs occur in up to 35% of older outpatients and 44% of older hospitalized patients, and account for one-tenth of all emergency department visits (19). Moreover, patients taking ≥7 medications have an approximately 80% risk of an ADR. The occurrence of an ADR is a natural time to discontinue a medication.
ADRs often have varied presentations. They may present asymptomatically (e.g., abnormal laboratory value), symptomatically (e.g., shortness of breath), or may be misattributed to a “normal process of aging” or symptoms of an underlying chronic disease (20,21). Medication-related harm in older adults may arise from use of medications that are associated with increased risk of harm in older adults (selected examples from the Beers criteria are shown in Table 1). Moreover, medications that are considered typically appropriate for older adults can also cause harm. Because medication adverse reactions are often misinterpreted as arising from an underlying disease or aging, any new unexplained symptoms should prompt a careful evaluation for a potential pharmacological basis.
An ADR may present as cardiovascular conditions (heart failure, elevated blood pressure, syncope, death) or noncardiovascular conditions (falls, gastrointestinal bleeding, dementia) (Table 2, Online Table 1). A contemporaneous example of a future ADR trigger presenting as a noncardiovascular condition is aspirin use for primary prevention. Multiple large randomized studies (2 in adults ≥70 years of age) have recently shown an increased risk of bleeding with minimal or no benefits in cardiovascular event reduction (22). This new knowledge may necessitate aspirin deprescribing for primary prevention. ADR may also present as hospitalization(s), permanent disability, or intervention to prevent permanent disability (23). Harm may also occur when medication use potentiates drug–drug interactions or when dosed inappropriately in patients with renal insufficiency (Table 3) (24,25). Notably, a meta-analysis of 13 trials in older adults, some that included deprescribing, demonstrated that pre-emptive interventions significantly reduced the risk of ADRs by 21% versus control subjects (23).
Polypharmacy is defined as long-term use of ≥5 medications, which is particularly common in multimorbid older adults (26). Overall polypharmacy prevalence among older adults increased from 24% in 2000 to 39% in 2012 (27) with a mean number of 7.2 medications in a community sample of ambulatory heart failure patients (11). Moreover, polypharmacy is associated with a higher risk of ADRs (6), reductions in physical and cognitive function, worsening of nutritional status, and increases in health care costs (28). Polypharmacy can be perpetuated by prescribing in the absence of an ongoing indication, which often occurs when a disease or symptom control medication is ineffective, or symptoms have resolved, but the medication is continued (e.g., nitrates after revascularization or resolution of angina).
Prescribing cascades are common, but not unique to older adults. They are a sequence of events that starts with the prescription of a drug, followed by an ADR that is misinterpreted as a new medical condition, leading to additional medication prescriptions to treat the drug-induced adverse event (29). One example is lower extremity edema, occasionally seen as a side effect of amlodipine. Instead of discontinuing amlodipine, a diuretic is prescribed with potassium supplementation. Other examples of prescribing cascades are the intensification of antihypertensive agents and heart failure medications among patients taking drugs known to increase blood pressure or exacerbate heart failure (24,25) (Table 2). Detecting prescribing cascades helps identify medications that can be discontinued in order to prevent future ADRs and reduce medication burden.
At end of life and as part of palliative care
A discussion of deprescribing as a palliative care strategy should be routine in older adults with CVD and an anticipated life expectancy of ≤2 years (30). The concomitant presence of multimorbidity, frailty and/or cognitive impairment in addition to the index CVD(s) should also trigger this conversation, even if life expectancy is >2 years. The deprescribing conversation should focus on shifting goals of care to symptom management, and reduction of ADRs and treatment burden (16,17,30). Although the incremental benefit of deprescribing in addition to palliative care is not fully known in patients with limited life expectancy (31), data demonstrate that deprescribing is acceptable to patients and their families (32). One randomized trial showed evidence of improved quality of life with such an approach (33).
Clinical Trials of Deprescribing
Deprescribing trials are increasing in number and differ from traditional prescribing trials designed to estimate the efficacy of starting a medication. First, the target populations in deprescribing trials often have a higher comorbidity burden and are closer to end of life. Second, deprescribing trials often include patients with mild or subclinical symptoms possibly related to medication use. Such trials may aid in a mechanistic understanding of the association between medication cessation and symptom improvement. Third, deprescribing trials can also be used to examine medication discontinuation safety, particularly when prescribing indications have changed because the underlying condition has improved either naturally or as a result of therapy (e.g., nitrates for angina following coronary revascularization).
Six completed or ongoing deprescribing-related studies (33–37) are shown in Table 4 with the details of the search strategy noted in Online Table 2. Due to space constraints, we focus in the following text only on studies that are completed, included adults ≥70 years, and took place in a non-nursing home environment, as these are felt likely to be most applicable to the cardiovascular team. The mean age in 2 of the 6 studies was around 55 years (35,37) with the mean age in the rest >70 years. All but 1 was multicentered, recruited ≥295 participants, and focused on antihypertensive and/or lipid-lowering medication therapy (36). The deprescribing process, as well as the primary and secondary outcomes, varied substantially between studies.
Findings from an important, albeit small, deprescribing study of younger individuals with heart failure deserves mention. Halliday et al. (37) addressed the safety of heart failure medication withdrawal in a randomized clinical trial of patients with recovered (ejection fraction ≥50%) dilated cardiomyopathy. Although more work is needed, this trial demonstrated that approximately 40% of participants relapsed when their heart failure medications were withdrawn, implying that long-term administration of heart failure medications is often, but not always, necessary (37).
Kutner et al. (33) examined statin discontinuation in patients with a life expectancy ≤1 year. Most participants (58.7%) had a history of CVD and statin use (68.3%) for ≥5 years. The median survival was 7 months with no difference in the proportion of deaths at 60 days between groups discontinuing and continuing statins (23.8% vs. 20.3%; p = 0.36). Statin discontinuation improved quality of life (total McGill quality of life score p = 0.04), reduced medication burden (p = 0.03), and reduced medication costs by $3.37 per day (95% confidence interval: 2.83 to 3.91).
The DANTE (Discontinuation of Antihypertensive Treatment in Elderly People) study Leiden deprescribing trial used a parallel-group, unblinded clinical trial design. Participants with mild cognitive impairment were randomized to either discontinuation or continuation of antihypertensive medications (34). At baseline, 11.2% of participants had CVD, 45.8% had orthostatic hypotension, and 61.5% took at least 2 antihypertensive medications. Employing a deprescribing algorithm developed by the study investigators, physicians withdrew antihypertensive treatment until a maximum of a 20–mm Hg increase in systolic blood pressure occurred. Deprescribing antihypertensive medications did not improve cognitive, psychological, or general daily functioning at 16 weeks of follow-up, but also did not increase adverse events. These findings should be placed in the context of the recently published SPRINT (Systolic Blood Pressure Intervention Trial) MIND trial (38). This substudy of SPRINT found a nonsignificant reduction in all-cause probable dementia (primary outcome), but a statistically significant reduction in the secondary outcome of incident dementia or mild cognitive impairment (20.2 vs. 24.1 cases/1,000 person-years; hazard ratio: 0.85; 95% confidence interval: 0.74 to 0.97) with intensive blood pressure therapy. Additional research is needed to define optimal blood pressure for reducing cognitive decline in older adults with hypertension.
Systematic reviews of deprescribing that included, but did not focus on, cardiovascular conditions or medications offer further insight into outcomes. A subgroup analysis of a systematic review of randomized trials to reduce polypharmacy suggested a potential mortality reduction (39). Other deprescribing benefits have included reduction in falls and improvements in cognitive and psychomotor function (5). Many studies examined the possibility of harm with deprescribing; however, no harm was demonstrated.
Attitudes, Barriers, and Enablers to Deprescribing
Current evidence finds that most older adults would prefer to decrease their medication burden and are open to discussions of medication deprescribing (40). One approach to initiate discussions with patients regarding deprescribing could be the use of such statements as “Sometimes medications are continued when the benefits don’t seem to be outweighing the risks. I believe that is the case for medication X and would like to discuss how you would feel if we remove it.” See Online Appendix Section 1 for further details.
Steps to Deprescribe
The decision and subsequent action to deprescribe should be undertaken using a holistic approach through an informed and shared decision-making process. This discussion should include patients, families, and appropriate clinical health care personnel (41) (see the Framework for Deprescribing section later in the text). A suggested step-by-step protocol for deprescribing (based on Scott et al. ) for cardiovascular clinicians is described in the following section and shown in the Central Illustration.
Step 1: Review and medication reconciliation
Reconciliation includes all prescribed and over-the-counter medications, their indications, and nonadherence patterns (42). Reasons for nonadherence may provide insight into otherwise-overlooked adverse effects (e.g., diuretic discontinuation due to urinary incontinence), patient concerns, and/or health priorities that warrant discussion with a health care professional. To aid busy clinicians, medication reconciliation and medication therapy management programs (43) support the use of pharmacists and other team members to collect, review, and analyze medication lists to identify potential drug interactions and therapeutic duplication, and to inform clinicians of possible nonadherence and potential avenues to improve prescribing (44).
Step 2: Risk assessment of adverse effects of individual medications
A fundamental tenet of deprescribing is to avoid future ADRs by paying close attention to current medication-related risks and patient-centric factors. Medication-related factors to consider include known ADRs, drug–drug or drug–disease interactions, and polypharmacy. Possible adverse effects must also be proactively investigated, because patients may not report them spontaneously. Potentially problematic medications have been identified by tools described later in the text (the Tools Used for Deprescribing section). Other risk assessment considerations include patient-related factors such as advancing chronological and physiological age, cognitive impairment which predisposes to ADRs and complexity of dosing schedules (45).
Step 3: Assess each drug’s eligibility for discontinuation
Medications used for symptom control in which the drug is ineffective and/or symptoms have resolved, those lacking in effectiveness, and medications without a current indication (e.g., long-term use of proton pump inhibitors) are potential candidates for deprescribing. For example, amiodarone in individuals with permanent atrial fibrillation may be discontinued if ventricular rates are otherwise well-controlled. Other medications that can be considered for removal are those that impose unacceptable treatment burden, such as due to burdens of monitoring, administration (e.g., multiple daily doses), or cost (46).
Step 4: Prioritize drug discontinuation
Prioritization should stem from a discussion with the patient and family to determine the optimal sequence of discontinuation. Prioritization should also be based on the risk/benefit balance, ease of discontinuation, risk for adverse drug withdrawal events (Table 5), and patient preferences.
Step 5: Discontinue medication(s) and implement monitoring protocol
Potential adverse effects and plans for monitoring should be discussed with the patient, akin to discussions about potential side effects and monitoring parameters that are expected upon drug initiation or up-titration. Medications should usually be discontinued 1 at a time so that any adverse effects or withdrawal symptoms can be attributed to discontinuation of a specific agent, with corrective action undertaken promptly. The rate of medication tapering should be cautiously undertaken in an evidence-based manner, if available, using individual clinical practice guidelines or drug monographs. Slow tapering over time may be prudent for some agents associated with increased risk for an adverse drug withdrawal event. These events may include a return of symptoms as a result of the withdrawal or a physiological withdrawal, such as rebound tachycardia after discontinuation of clonidine (47) (Table 5).
Framework for Deprescribing
To overcome the barriers and clinical inertia to deprescribing, it is useful to have a framework to draw upon during discussions with patients, families, and colleagues. Two methods are the “domain management model” (4), described recently in the context of caring for older adults with heart failure but relevant across the spectrum of CVD, and the “5M model” (48). The 5Ms, a mnemonic to highlight meaningful care issues in older adults (Mind, Mobility, Medications, Multimorbidity, and Matters Most), is complementary to the domain management model (medical/surgical, physical, cognitive, and social domains). Their complementary importance is in providing a framework for a holistic approach to patient care that necessitates the consideration of conditions and relevant contributing factors outside the index cardiovascular condition(s) being addressed (e.g., assessments of frailty, activities of daily living, fall risk, cognitive function [dementia, delirium, depression], and social environment) (see Table 6 for a real-world deprescribing example).
Tools Used for Deprescribing
Several tools, predominantly focused on care of older adults, are available to identify medications that may be appropriate for deprescribing (49). These tools have been divided into implicit and explicit tools. They attempt to address the polypharmacy burden, ADR risk, medication regimen optimization, and the decision-making required to implement the deprescribing process. Implicit tools apply a framework to evaluate drugs and include the ARMOR (Assess, Review, Minimize, Optimize, Reassess) tool (Online Table 3A) and the GPGP (Good Palliative-Geriatric Practice) algorithm (Online Table 3B).
Explicit tools are protocoled lists. They include the American Geriatrics Society (AGS) Beers criteria (already well-integrated into some electronic health systems) (Tables 1, 2, and 3, Online Tables 1 and 4), STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions) criteria (Online Table 3C), and internet tools (Online Section 2). The AGS Beers Criteria is an evidence-based, expert consensus list of medications that are often inappropriate in older adults due to excess risk of harms and/or limited benefits in this population (25). For this review, our primary focus has been on CVD medications. The STOPP criteria, relevant to deprescribing and identifying potentially inappropriate medications, include 65 indicators addressing drug–drug and drug–disease interactions, risks of falls, and medication class duplication. For persons approaching end of life, the STOPPFrail (STOPP in Frail Adults with Limited Life Expectancy) (50) tool is a particularly useful reference (Online Table 3D). Reviewing these before a coordinated cardiovascular and palliative care/hospice team discussion may be useful for consensus building surrounding specific medications and the approach to deprescribing.
The deprescribing process can be initiated anywhere (inpatient or outpatient) or by anyone on the health care team (including patients, or their surrogates). Building efficient communication lines between and within teams is the key to successful comanagement of cardiovascular and noncardiovascular medications (8,39). For example, if the cardiologist identifies a high-risk or overtly harmful noncardiovascular medication, then the cardiologist can: 1) inform the primary care clinician and the patient to ensure that concerns are raised with the primary care clinician; or 2) the cardiologist can stop or change the medication and communicate this to the patient and primary care clinician (or another prescriber). In either case, direct communication between all involved is paramount. Future research on the effectiveness of using pharmacists in collaborative practice protocols may enhance acceptance of deprescribing as part of routine cardiovascular care.
Payment for Deprescribing
Although there are no specific billing codes for deprescribing, the time and complex decision-making involved in the process fulfill the criteria for higher level of care and medication risk management.
The continuum of good prescribing practices includes the deprescribing process. The cardiovascular clinical team must recognize, particularly in reference to older adults, that deprescribing is an important resource that can improve clinical care and enhance quality of life. Evidence to support cardiovascular medication deprescribing, tools to facilitate it, and models of care coordination between cardiovascular specialists and generalists are evolving. Further research (Table 7) will improve understanding of the deprescribing process and its impact on clinical care, patient-centered outcomes, and costs. The cardiovascular clinical community is on the threshold of an opportunity to improve medication safety and reduce ADRs, particularly among older adults, by implementing the principles of deprescribing into daily patient care as a key component of an appropriate prescribing spectrum.
The views expressed in this paper by the American College of Cardiology’s Geriatric Cardiology Section Leadership Council does not necessarily reflect the views of the Journal of the American College of Cardiology or the American College of Cardiology.
The current work was supported in part by National Institutes on Aging (NIA) grant # U13 AG047008 to Dr. Rich. Dr. Steinman was supported by National Institutes of Health grant AG-K24049057. Dr. Maurer was supported by NIA grant K24 AGO36778. Dr. Tjia was supported by the Cambia Health Foundation Sojourns Scholar Award; and has been a consultant to CVS Health and Omnicare Long Term Care Pharmacy. Dr. Zullo has received institutional research support from Sanofi Pasteur. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The current paper evolved from the “Pharmacotherapy in Older Adults with Cardiovascular Disease” conference sponsored by the American College of Cardiology, American Geriatric Society, and National Institutes of Aging held at ACC Heart House in Washington, DC, on February 6 to 7, 2017.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Abbreviations and Acronyms
- adverse drug reaction
- cardiovascular disease
- Screening Tool of Older People’s Potentially Inappropriate Prescriptions
- Received February 22, 2019.
- Accepted March 12, 2019.
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- Central Illustration
- Definition of Deprescribing
- Rationale for Deprescribing
- Ethical Basis for Deprescribing
- Triggers to Deprescribe
- Clinical Trials of Deprescribing
- Attitudes, Barriers, and Enablers to Deprescribing
- Steps to Deprescribe
- Framework for Deprescribing
- Tools Used for Deprescribing
- Deprescribing Workflow
- Payment for Deprescribing