Background: The perspectives of patients and healthcare professionals regarding deprescribing in surgical wards within hospital settings are unknown. Objective: To explore current practices, attitudes, and the enablers and barriers to deprescribing in hospital for older surgical inpatients from the perspectives of doctors, pharmacists, patients and carers. Methods: A mixed methods study was performed. Two surveys were administered Australia-wide (revised Patients’ Attitudes Towards Deprescribing questionnaire for patients/carers and Deprescribing Self-Efficacy Survey for doctors/pharmacists). Interviews, focus groups and observations of ward rounds were conducted with participants from five Australian hospitals. Quantitative data were analysed descriptively, while qualitative data were examined using a combined inductive and deductive approach, with results triangulated. Results: There were 109 survey participants (58 doctors/pharmacists and 51 patients/carers), 28 interview/focus group participants (15 doctors/pharmacists and 13 patients/carers) and eight ward round participants. Doctors and pharmacists reported low to moderate levels of confidence in deprescribing. While most patients and carers were satisfied with their medications, they expressed a willingness to consider deprescribing. Five themes were identified from the interviews, focus groups and ward round observations; 1) deprescribing is not a priority, 2) medication review occurs in response to triggers, 3) knowledge about deprescribing is limited, 4) deprescribing requires a team effort and 5) trust, rapport and communication are essential for successful deprescribing. Conclusions: Doctors working on surgical wards are unlikely to proactively deprescribe medications. A collaborative patient-centred approach involving geriatricians, clinical pharmacologists and pharmacists, along with educational interventions may facilitate deprescribing for surgical patients.

Aim: To investigate if interventions to discontinue or down-titrate heart failure (HF)-pharmacotherapy are feasible and associated with risks in older people. Methods: A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to March 8th 2023. Randomised controlled trials (RCTs) and observational studies included people with HF, aged >50 years and who discontinued or down-titrated HF-pharmacotherapy. Outcomes were feasibility (whether discontinuation or down-titration of HF-pharmacotherapy was sustained at follow-up) and associated risks (mortality, hospitalisation, adverse drug withdrawal effects [ADWE]). Random-effects meta-analysis was performed when heterogeneity was not substantial (Higgins I2<70%). Sub-analysis by frailty status was conducted. Results: Six RCTs (536-participants) and 27 observational studies (810,499-participants) across six therapeutic classes were included, for 3-260 weeks follow-up. RCTs were conducted in patients presenting with stable HF. Down-titrating a renin-angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% likely than continuation (Risk Ratio [RR] 1.76, 95%CI 1.14-2.73), with no difference in mortality (RR 0.64, 95%CI 0.30-1.64). Discontinuation of beta-blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95%CI 0.68-1.47). Participants were 25% likely to re-initiate discontinued diuretics (RR 0.75, 95%CI 0.66-0.86). Digoxin discontinuation was associated with 5.5-fold risk of hospitalisation compared to continuation. Worsening HF was the commonest ADWE. One observational study measured frailty but did not report outcomes by frailty status. Conclusions: The appropriateness and associated risks of down-titrating or discontinuing HF-pharmacotherapy in people aged >75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.

The emerging issue of rising gabapentinoid misuse is being recognised alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23rd February 2022 without restrictions. Eligible studies included randomised, non-randomised and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated type of intervention, prescribing rates, cessations, patient outcomes, and adverse events. Extracted outcome data was categorised as either short (≤ 3 months), intermediate (>3 but <12 months) or long (≥ 12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Intervention were of dose reducing protocols, education and/or pharmacological-based approaches. In the randomised trials, gabapentinoid use could be ceased in at least one-third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focussed psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area.

Background and aims: Opioids are commonly prescribed to patients with chronic low back pain (LBP) despite risks of harms. We conducted a discrete choice experiment (DCE) to determine factors contributing to a general practitioner’s (GP’s) decision to prescribe either an opioid or an NSAID to a patient with chronic LBP. Methods: GPs recruited through an online survey distributed in Australia were presented with 12 questions that represented hypothetical clinical scenarios of a patient with chronic LBP. The clinical scenario varied by two patient attributes; LBP with or without referred leg pain (sciatica) and comorbidities. Participants chose their preferred alternative either an opioid, NSAID or neither (“opt-out”). Each alternative varied by three clinical attributes: the type of opioid or NSAID, the degree of pain reduction and number of adverse events. Results: 210 GPs participated in the survey. Overall, GPs preferred to prescribe an NSAID (45.2%, 95% CI 38.7% to 51.7%) over an opioid (28.8%, 95% CI 23.0% to 34.7%). However, there was no difference between the type of NSAID or opioid preferred. Patient attributes of comorbidities (zero, one, two or three), and the presence of referred leg pain (sciatica) did not influence prescribing preferences, nor did clinical attributes of pain reduction and adverse events. Conclusions: GPs prefer to prescribe an NSAID over an opioid for a patient with chronic LBP. This preference appeared fixed and was not changed by clinical (drug type, degree of pain reduction or number of adverse events) or patient attributes (comorbidities or presence of referred leg pain).

Rationale, aims and objectives: People living with dementia admitted to hospitals are more likely to experience poorer outcomes than people without dementia. Caregivers play an important role in managing medications across transitions of care. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge. Methods: A qualitative approach using semi-structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives. Results: Caregivers’ experiences of medication guidance for people with dementia at discharge were described in three themes including: a) inadequate information about medication management at discharge; b) limited caregiver engagement in medication management decisions; and c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication-related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient’s cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co-ordination post transition. Discussion: In our study of caregivers of people with dementia, we identified key recommendations that could be tested to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge.