One area of
focus of the Bruyère Evidence-Based Deprescribing Guidelines Symposium held in
March 2018 was encouraging the routine inclusion of deprescribing
recommendations in clinical guidelines. Clinical guidelines often do not
accommodate frailty or patients with multiple comorbid conditions. This can
give rise to complex medication regimens and risk of medication harm. Despite
monitoring and stopping treatment being a key part of rational prescribing, deprescribing is often overlooked in general and in the context of guidelines. There
are several challenges to increasing deprescribing recommendations in clinical
guidelines. These include limited evidence on the effects of deprescribing,
lack of awareness among guideline developers, potential conflicts of interest,
and lack of incentives for deprescribing research. To date, medicines
regulators, payers, governments, and journals have not encouraged the inclusion
of deprescribing recommendations in guidelines. The Grading of Recommendations
Assessment, Development and Evaluation (GRADE) system could address some of
these challenges through its focus on values and preferences, distinct rating
of quality of evidence and strength of recommendations, downgrading quality due
to indirect evidence, and an explicit approach to conflicts of interest.
Further work to adapt GRADE methods to deprescribing could be of benefit.
Establishing deprescribing recommendations as a routine part of clinical
guidelines is an important opportunity to improve evidence-based clinical
practice, and ultimately, patient care.</p