Characteristics, Content And Language Of Deprescribing Recommendations In Clinical Practice Guidelines: A Scoping Review

• By: LANGFORD, Aili (Centre For Medicine Use And Safety, Monash University, Australia)
• Co-author(s): Dr Aili Langford (Centre For Medicine Use And Safety, Monash University, Parkville, Australia)
  Ms Imaan Warriach (University College London School of Pharmacy, London, United Kingdom)
  Dr Justin Turner (Centre For Medicine Use And Safety, Monash University, Parkville, Australia)
  Dr Wade Thompson (Faculty of Medicine, University of British Columbia, Vancouver, Canada)
  Dr Barbara Farrell (Bruyère Research Institute, Ottawa, Canada)
  Dr Danielle Pollock (Health Evidence Synthesis Recommendations and Impact, The University of Adelaide, Adelaide, Australia)
  Dr Frank Moriarty (School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland)
  Associate Professor Danijela Gnjidic (School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia)
  Dr Nagham Ailabouni (School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Queensland, Australia)
  Dr Emily Reeve (Centre For Medicine Use And Safety, Monash University, Parkville, Australia)
  
• Abstract:

  Background information: Adherence to prescribing recommendations in clinical practice guidelines may contribute to inappropriate polypharmacy. Healthcare professionals, including pharmacists, require evidence-based recommendations to ensure safe and effective prescribing and deprescribing (medication dose reduction or cessation). The extent to which deprescribing recommendations are included in clinical practice guidelines is unclear.
  
  Purpose: To determine the proportion and characteristics of clinical practice guidelines that contain deprescribing recommendations, and to explore the content and language of these recommendations.
  
  Method: A random 10% sample of all clinical practice guidelines published in the past five years from four international guideline registries (Guidelines International Network [GIN], Canadian Medical Association Infobase [CPG infobase], MAGICapp, and GuidelineCentral) were screened in duplicate to determine the proportion of guidelines containing one or more deprescribing recommendations. Additionally, three databases (Medline, EMBASE and CINAHL Plus) and Google were searched for guidelines published in the last ten years containing one or more deprescribing recommendations. We included guidelines which met the Institute of Medicines definition and criteria of a clinical practice guideline and excluded guidelines focussing on acute treatment only (e.g. related to surgery or interventional investigations, or medicines prescribed short term for an acute condition). Guideline characteristics were extracted, including year and country of development, total number of recommendations, number of deprescribing recommendations, and whether or not a consumer was involved in guideline development. The content and language of recommendations were examined using a conventional content analysis, with two independent reviewers applying the coding framework. The SheLL Health Literacy Editor tool was used to quantify the readability and complexity scores of each recommendation.
  
  Results: Approximately 28% of guidelines identified in the guideline registry search contained one or more deprescribing recommendations. A total of 81 guidelines containing 316 deprescribing recommendations were identified and included in the review. An upward trend in the number of guidelines containing deprescribing recommendations was observed over the ten-year period. The majority of guidelines were on topics relating to the nervous system (e.g. opioids, dementia), and antineoplastic and immunomodulatory agents (e.g. rheumatology guidelines). Only 9% of all recommendations (316 of 3569 recommendations) pertained to deprescribing and there was significant variability in the terminology used (e.g. taper, cease, discontinue). Most included guidelines (91%) contained recommendations on ‘when’ to deprescribe, yet less than half (40%) provided detailed guidance on ‘how’ to deprescribe. Guidelines with noted consumer involvement in development had more patient-centred recommendations and less complex language.
  
  Conclusion: Deprescribing recommendations are becoming more common in clinical practice guidelines, however, there is significant variability in their content and language. Few guidelines contain clear and actionable recommendations on ‘how’ to deprescribe, likely inhibiting implementation of recommendations in clinical practice. Integration of more specific and comprehensive deprescribing recommendations into clinical practice guidelines may better enable pharmacists to deliver evidence-based care and promote quality use of medicines through reduction of inappropriate polypharmacy.