Regular MedShadow readers are likely familiar with the idea of deprescribing—the process of reducing the number or dose of drugs a person is taking. MedShadow has written about the phenomenon before. But, while the idea of taking fewer medications is simple, the real world process of deprescribing while balancing risks versus benefits is complicated. Some medications have withdrawal symptoms, and tapering may take time.
The Therapeutics Initiative at the University of British Columbia (UBC) is hosting a series of webinars with healthcare professionals sharing real-life stories about their own patients whose medications they were able to reduce, and what happened when they did. To bring deprescribing to life, healthcare professionals are sharing the stories of their patients.
The following story is the second in our deprescribing series. It’s the story of a patient that Nikki Domansky, PharmD, a clinical pharmacist with UBC, calls TOM (an acronym for Taper Off Medications, to protect his privacy.)
How One Man was Prescribed 14 Medications
At only 33 years old, Tom had chronic pain as a result of two car accidents. His physicians had prescribed six drugs to treat his pain, four drugs for his moods, one to improve his focus and alertness, then one each for cholesterol, blood pressure, and erectile dysfunction. As his prescriptions cascaded, Tom ended up taking a total of 14 prescription drugs each day, prescribed by more than four different doctors.
Just before meeting with Domansky, he’d had a procedure to implant a spinal cord stimulator, a device that gave small electrical shocks to his spine in hopes of minimizing his pain. Unfortunately, much of his pain remained.
Tom suspected that most of his drugs weren’t doing much to help him. Plus, while taking them he’d developed brain fog, dizziness, fatigue, and a hand tremor, all of which he found troubling.
Tom was motivated to try and reduce his medications, so the pain clinic he typically visited sent him to the UBC Pharmacists Clinic to see if a pharmacist, with specialized knowledge of medication interactions, Domansky, could help him lower his medications.
“When I asked him about goals of therapy, the first thing he said was that he wanted to think more clearly and help out with more responsibilities around the house,” says Domansky. “He just wanted to be a better dad and a better partner.”
The Pharmacist’s First Steps to Deprescribing
Domansky said she always starts the process of deprescribing with education. One crucial fact for patients to understand is that, if they lower or stop a medication and symptoms return, it’s OK for the patient and doctor to decide to start that medication again.
“I often have so many patients who are fearful of tapers because they think that once we reduce the dose or take it off and their pain gets worse, we can never put it back on,” she said.
Once she made sure Tom understood the process, she asked Tom which medications he felt were helping him. He pointed out two drugs he had started more recently that he felt were helpful—one was for pain and the other to help him focus. The rest, he said, he’d been taking for so long it was hard to tell what worked.
Many of Tom’s medications could be contributing to his side effects, so Domansky decided to start with what she referred to as the “lowest hanging fruit” methocarbamol/ibuprofen, a muscle relaxer.
It’s an easier drug to stop taking, she explained, because there’s no taper required. You can safely just stop taking it. It’s also known to contribute to symptoms like brain fog.
Stopping the methocarbamol/ibuprofen went smoothly. In fact, it was one of the few medications Tom had to pay for out of pocket, too, so he even saved some money.
When Doctors Don’t Communicate
Next, Domansky turned to two psychotropic medications—lamotrigine and buspirone—both of which are typically used to treat anxiety and depression associated with bipolar disorder. While Tom did experience depression and anxiety, both he and his doctors confirmed he had never been diagnosed with bipolar disorder.
Domansky noted that he was taking another mood stabilizing drug, carbamazepine, which is known to interact with lamotrigine and buspirone, reducing their effects. She wondered, given the low doses he was on, if these medications were having any effect at all or if the therapeutic impacts had been canceled out by the carbamazepine.
Domansky called Tom’s psychiatrist. The psychiatrist said the drugs had been prescribed for “induced bipolarity,” a condition in which you develop manic and depressive symptoms as a side effect of taking other drugs.
At first, the psychiatrist was opposed to any sort of deprescribing. The psychiatrist told her that she should not touch the prescriptions, and that Tom didn’t know what was best for him. But after a long discussion, Domansky and the psychiatrist made a plan. Tom could taper off of the buspirone and another drug, gabapentin, an antiepileptic drug sometimes used as a mood stabilizer, instead of the lamotrigine.
Domansky couldn’t find any known guidelines for tapering buspirone, so she developed a schedule for Tom based on the time it takes the drug to leave the body. That taper was successful, and Tom was able to completely stop taking buspirone without reporting any new or worsening symptoms, known risks of stopping antianxiety and antidepressant medications.
Deprescribing is Still an Imperfect Science
Next up on the dose-chopping block was gabapentin. It turned out that the psychiatrist Domansky had spoken with had prescribed the buspirone, but not the gabapentin. Gabapentin had been started by a different doctor. Tom and Domansky decided to skip discussions with that prior doctor and move forward with tapering the drug.
After several weeks of gradual tapering, Tom had managed to get completely off of the gabapentin. Unfortunately, that’s when he started experiencing some new pain in his ribs. They began to gradually re-introduce the dose to relieve his pain.
Despite having to start taking gabapentin again, Tom remained motivated to reduce his medications, so Domansky reviewed his prescriptions and identified another that was likely to be clouding his mind: Nabilone. The drug is usually prescribed to help with nausea associated with chemotherapy, but in some cases it may be useful for treating nerve pain associated with fibromyalgia.
He’d been taking a low dose, and the body takes a long time to gradually get rid of nabilone. Without existing guidelines, Domansky recommended Tom just stop taking the drug. Two weeks later, he had no new pain or other symptoms. It had been “another pointless drug,” said Domansky.
Deprescribing: Slowly but Surely
Tom’s deprescribing journey started in July of 2022. As of April 2023, he’s managed to reduce three of his drugs without sacrificing his quality of life, and he’s thrilled with the progress. He hopes to continue reducing his medicines over time.
Domansky plans to revisit the option of reducing his lamotrigine and even gabapentin in the future, which she thinks will require a “team effort” with his other healthcare providers.
She said her experience with Tom has two main takeaways. First, Domanksy said, “there is no one-size-fits-all approach towards deprescribing. Most of the time, you’re not going to have… published tapering protocol or guidelines,” to work with. You may have to make decisions without that type of established, researched support. The second takeaway is that “if you try and fail, that doesn’t mean you can’t try again in a few months or years down the line.”
Read another story about a patient’s deprescribing journey: