Polypharmacy - Deprescribing Using STOPP START Approach

Key Points

• Polypharmacy is a quality problem when medication burden exceeds expected benefit, not merely when the drug count is high.
• Reconcile what the patient actually takes, including OTC products and supplements.
• STOPP/START and Beers Criteria are screening tools that support, rather than replace, individualized judgment.
• Search actively for prescribing cascades and duplicate pharmacology.
• Prioritize deprescribing of medications with no indication, clear harm, or very low chance of meaningful benefit.
• Some drugs require gradual tapering to avoid withdrawal or rebound.
• Deprescribing needs a monitoring plan and follow-up.
• Also look for beneficial therapies that are unintentionally omitted.

Algorithm

1. Create an accurate medication list from patient, caregiver, pharmacy, and records when needed.
2. For each medicine, confirm indication, benefit, harm, dose appropriateness, and time to benefit.
3. Apply structured tools such as STOPP/START and Beers as prompts.
4. Identify high-risk combinations, prescribing cascades, and medications contributing to current symptoms.
5. Prioritize changes based on harm, goals, and patient preference.
6. Taper drugs with withdrawal risk and stop low-risk agents directly when appropriate.
7. Document monitoring targets and a follow-up date.
8. Communicate the revised list to all prescribers and the dispensing pharmacy.

Clinical Synopsis & Reasoning

Polypharmacy is not defined solely by a medication count. Five appropriate medicines can be safer than three inappropriate ones. The clinically important problem is medication burden that increases adverse effects, interactions, nonadherence, cost, falls, cognitive impairment, bleeding, hypoglycemia, kidney injury, or hospitalization without sufficient expected benefit. Start with a complete medication reconciliation that includes prescriptions, over-the-counter products, supplements, inhalers, eye drops, as-needed drugs, and medicines obtained from multiple clinicians or pharmacies. Confirm what the patient actually takes, because the electronic list frequently differs from real use.

For each drug, document indication, expected benefit, time to benefit, current response, adverse effects, monitoring needs, duplication, renal and hepatic dose appropriateness, and whether the medication still aligns with life expectancy and patient priorities. STOPP criteria highlight potentially inappropriate medicines in older adults, while START criteria highlight evidence-based therapies that may be omitted. The 2023 STOPP/START version 3 and the 2023 AGS Beers Criteria provide structured prompts, but neither should be applied mechanically. Some flagged medications remain appropriate when alternatives are ineffective or a strong indication exists.

Look for prescribing cascades, such as treating calcium-channel-blocker edema with a diuretic or treating cholinesterase-inhibitor urinary symptoms with an anticholinergic. Symptoms such as falls, constipation, confusion, urinary retention, orthostasis, anorexia, tremor, or sleep disturbance may be medication effects rather than new diseases. High-risk combinations include multiple sedatives, concurrent anticholinergic drugs, opioids with benzodiazepines, anticoagulants with unnecessary antiplatelets, and regimens that produce recurrent hypoglycemia.

Treatment Strategy & Disposition

Deprescribing is a planned clinical intervention, not medication abandonment. Prioritize drugs with no current indication, clear harm, therapeutic duplication, or very low likelihood of benefit. Engage the patient or surrogate in deciding which outcomes matter most, such as maintaining alertness, avoiding falls, reducing pill burden, preventing stroke, or controlling symptoms. Stop one or a small number of medications at a time when attribution of withdrawal or symptom recurrence matters. Some agents can be stopped directly, while benzodiazepines, corticosteroids, beta blockers in selected circumstances, clonidine, antidepressants, anticonvulsants, and several other drugs may require tapering.

After every deprescribing change, define what will be monitored and when. Rebound symptoms do not always mean the drug must be permanently restarted; they may require a slower taper, a nonpharmacologic strategy, or an alternative medication. Conversely, omission of beneficial therapy can also be harmful. START criteria are useful reminders to assess indicated anticoagulation, osteoporosis therapy, cardiovascular prevention, vaccination, or other evidence-based treatment when clinically appropriate.

Medication review is especially valuable after hospitalization, a fall, delirium, renal-function decline, transition to hospice, or a new diagnosis that changes prognosis. Coordinate changes across prescribers and document the rationale to prevent an automatically renewed medication from reappearing. Pharmacy involvement can improve interaction review and simplify dosing schedules. The end product should be a medication list that is understandable, necessary, tolerable, and aligned with current goals.

Epidemiology / Risk Factors

• Medication burden increases with multimorbidity and fragmented care.
• Adverse drug events account for substantial preventable morbidity in older adults.
• Transitions between hospital, rehabilitation, and home are high-risk periods for discrepancies.
• Frailty and renal or hepatic impairment increase vulnerability to drug toxicity.

Investigations

Common Deprescribing Targets

Pharmacology

Prognosis / Complications

• Thoughtful deprescribing can reduce adverse effects and pill burden without worsening disease control.
• Abrupt withdrawal of certain drugs can cause clinically significant harm.
• Benefits are greatest when medication changes are paired with follow-up and clear ownership.
• Medication review is iterative because indications, physiology, and goals change over time.

Patient Education / Counseling

• Explain why each medication is being continued, changed, or stopped.
• Provide a written updated list after every major review.
• Tell patients which medications must not be stopped abruptly.
• Ask them to bring all bottles, supplements, and OTC products to reviews.
• Discuss the tradeoff between long-term prevention and current symptom burden in advanced illness.
• Encourage one coordinating clinician or pharmacist when many specialists prescribe.

Notes

A high-quality medication review ends with a defensible plan, not simply a shorter list. The safest approach is to preserve medicines with meaningful benefit, remove or taper medicines that are harmful or obsolete, and make sure important treatments have not been omitted. Revisit the plan after acute illness, falls, renal decline, or a change in goals because medication appropriateness is dynamic.

References

1. STOPP/START criteria for potentially inappropriate prescribing in older people, version 3 — Link
2. American Geriatrics Society: 2023 AGS Beers Criteria — Link