By Ryan DuBosar
Once a prescription is started, it can linger on, hiding in the medical record, dodging multiple prescribers, while giving a patient a false sense of its necessity. Patients can wind up on a dozen prescriptions, risking interactions and side effects that lead to a cascade of further prescribing.
Cynthia M. Boyd, MD, MPH, FACP, met a patient with a simple solution to this problem.
“I actually once had a patient who said to me that she would take three medicines that I could choose, but she only wanted to take three,” she said, drawing chuckles from her audience at an Internal Medicine Meeting 2025 talk titled, “Deprescribing: ‘Doc, I Take Too Many Medications!’”
She cited statistics showing how many patients could make that plea. Two-thirds of older Americans take five or more medicines daily, and 17% take more than 10. Up to half of older adults who are taking proton-pump inhibitors have no discernible indication for them and one-third of older patients take a guideline-recommended drug to help one condition that may worsen another one.
It is hard to deprescribe drugs, in part because there are not a tremendous number of guidelines about the topic and physicians are often not thinking about it amid the bustle of patients seeking treatment, said Dr. Boyd, a geriatrician and professor of medicine at Johns Hopkins University in Baltimore.
“And I do think that inertia keeps things going,” she continued. “Whenever I get a refill request in between visits for a [proton-pump inhibitor], the patient's not in front of me, and I'm like, 'Oh, maybe we should talk about whether or not they really need it.' But it's much harder to do that when the patient's not in front of you. It's much easier to just click ‘refill.’”
Deprescribing involves making choices about what meds to target and when, Dr. Boyd noted. “The process of stopping a medicine or reducing the dose is not the reverse of just starting it,” she said.
To guide their thinking on deprescribing, Dr. Boyd referred her audience to the Institute for Healthcare Improvement's national movement to create age-friendly health systems, with its four pillar “M's”: what Matters, Mobility, Medication, and Mentation.
“As we're trying to help older adults manage a variety of health conditions, there is a level of complexity that arises that we have to be trying to address,” Dr. Boyd said. So she adds a fifth “M” for multicomplexity (more often called multimorbidity, she noted). "We need to start shifting our framework from one where we're thinking about specific diseases to one that better addresses multimorbidity,” she said.
Getting patients on board is another important component of deprescribing and their reactions can vary. Dr. Boyd cited research finding that most patients said that if their doctor said it was possible, they would be willing to stop one or more of their regular medicines, and about 70% said that they would like to reduce the number of medicines they take.
“Many times we as physicians think people aren't going to want to stop things … but I think it's important to not assume that," she said, noting that it's on the physician to start the conversation. "Many of our patients actually don't necessarily feel comfortable raising this with us or know that it's a thing that we can do.”
Patients may also feel their medications are essential because a physician has told them so.
“I remember trying to stop aspirin in a patient in her 90s that came to me for primary care who only had hypertension and she was having a lot of bruising,” Dr. Boyd said. A prior physician had told the family she’d be on aspirin the rest of her life, because if she stopped it, she'd have a heart attack and die.
“I'm pretty sure that's not what the doctor said, but that was what the family heard, right?” said Dr. Boyd.
She advised her attendees to simplify later deprescribing with their wording at the time of a new prescription. “When I start medicines, I try really hard to always say, ‘Look, I think this is the right thing for you now, but I'm going to continue to re-evaluate whether you're going to still need this medicine, and your need for this medicine may actually change over time.’” ■