Deprescribing recommendations: an essential consideration for clinical guideline developers
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.