Deprescribe During an Inpatient Stay

Over 40% of older patients receive at least one unnecessary prescription at discharge.

Continue to assist with reconciling meds prior to discharge.

Stop meds started for hospital conditions, such as PPIs for stress ulcer prophylaxis or antipsychotics for ICU delirium.

Keep in mind to stop prns from hospital order sets...sliding scale insulin, opioids, antacids, etc.

And switch therapeutic interchanges back to the home med.

Also think about steps you can take earlier in a hospital stay.

One strategy is to deprescribe. Reducing pill burden and cost is linked to improved adherence...and may save nursing time.

Some hospitals have decision support software to help. But if you don’t, work with IT to create reports with deprescribing criteria.

Start by incorporating high-risk patients and meds into your daily review...such as focusing on older patients taking potentially inappropriate meds.

For example, assess patients on dual antiplatelet therapy (DAPT). Most should step down to one med by 3 weeks after a stroke.

And most patients with coronary stents can stop DAPT by 12 months. Those with stable disease can stop sooner... 6 months or less.

Also consider stopping aspirin for CV PRIMARY prevention, especially in patients over 70. Risks usually outweigh benefits.

Target deprescribing of sleep meds, such as benzos and “Z-drugs” (zolpidem, etc)...due to fall risk. Educate on sleep hygiene...and if needed, consider low-dose melatonin, such as 3 mg.

Also evaluate muscle relaxants. Most symptom relief is likely due to sedation. Plus they’re linked to respiratory depression and death when used with other CNS depressants.

Suggest nondrug strategies for chronic low back pain instead of muscle relaxants. Add an NSAID if appropriate.

Investigate chronic PPI use. PPIs generally aren’t intended long-term...and GERD treatment can usually be stopped after 8 weeks.

When deprescribing, keep in mind that some meds may need to be tapered...such as benzos, opioids, or PPIs.

Get our resources, Potentially Harmful Drugs: Beers List and Chronic Meds in the Elderly: Taking a “Less Is More” Approach, for other deprescribing opportunities.

Key References

  • Am J Health Syst Pharm. 2022 Nov 22;79(Suppl 4):S128-S135
  • JAMA Intern Med. 2022 Mar 1;182(3):265-273
  • JAMA Intern Med. 2023 Mar 1;183(3):223-231
  • Evid Based Med. 2013 Aug;18(4):121-4
  • J Am Geriatr Soc. 2005 Sep;53(9):1518-23
Hospital Pharmacist’s Letter. May 2023, No. 390517

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