| Current Medication Regimen | ||
|---|---|---|
| Medication | Dose | Frequency |
| Potassium chloride | 20 mEq | Once daily |
| Omeprazole | 20 mg | Twice daily |
| Acetaminophen | 650 mg | Twice daily |
| Tramadol | 50 mg | Twice daily |
| Lisinopril | 10 mg | Once daily |
| Atorvastatin | 20 mg | Nightly |
| Sertraline | 50 mg | Once daily |
| Levothyroxine | 75 mcg | Once daily |
| Calcium carbonate | 500 mg | Twice daily |
| Vitamin B12 | 1,000 mcg | Once daily |
Systematic Deprescribing and Polypharmacy Reduction in an Older Adult
Patient Background
Mrs. Robbin. is a 79-year-old female who presented for a comprehensive medication review as part of routine geriatric care. Her medical history included hypertension, hyperlipidaemia, gastroesophageal reflux disease (GERD), chronic musculoskeletal pain, depression, primary hypothyroidism, and a previous history of hypokalaemia. Her current medication regimen is shown below.
Clinical Presentation
During the consultation, Mrs. Robbin reported that her reflux and chronic pain had remained well controlled. She could not recall why potassium supplementation had been continued and reported that a diuretic she had previously taken for peripheral oedema had been discontinued several months earlier. Recent renal function and serum potassium measurements were within the normal range.
Clinical Issue Identified
Comprehensive medication reconciliation identified several potential deprescribing targets. Some medications appeared to have been continued after their original indication had resolved, while others could potentially be reduced because the patient’s symptoms were stable.
Of particular concern was continued potassium chloride supplementation without an apparent ongoing potassium-wasting medication or documented current requirement. The potassium supplement had apparently remained on the medication list after discontinuation of the patient’s diuretic.
Scheduled tramadol represented another potential deprescribing target. Her pain was currently well controlled while receiving both tramadol and acetaminophen. Continued opioid exposure could contribute to sedation, dizziness, constipation, falls, and drug interactions. Furthermore, concomitant tramadol and sertraline increases serotonergic burden and may increase the risk of serotonin toxicity and seizures.
The indication for omeprazole 20 mg twice daily was also reassessed. In the absence of persistent symptoms or another indication for long-term high-dose acid suppression, twice-daily therapy appeared potentially unnecessary. Long-term proton pump inhibitor therapy may also contribute to nutrient malabsorption, including vitamin B12 deficiency in susceptible patients.
Finally, the ongoing indications for calcium carbonate and vitamin B12 supplementation required clarification rather than automatic discontinuation.
Pharmacist Intervention and ClinicalManagement
Reassess potassium supplementation
The indication for potassium chloride should first be confirmed by reviewing previous electrolyte results, renal function, and the reason supplementation was originally initiated. Because the potassium-wasting diuretic had been discontinued and current potassium concentrations were normal, potassium chloride could be considered for discontinuation with follow-up serum potassium monitoring.
This is particularly important because the patient remains on lisinopril, which can increase serum potassium. Continuing unnecessary potassium supplementation could therefore predispose her to hyperkalaemia, particularly if renal function subsequently deteriorates.
Rationalise chronic analgesic therapy
Given stable pain control, the continued requirement for scheduled tramadol should be reassessed. If clinically appropriate, tramadol should be gradually tapered rather than abruptly discontinued, particularly after prolonged regular use.
Acetaminophen could be retained initially as the lower-risk analgesic, with subsequent reassessment of whether scheduled administration remains necessary or could be changed to as-needed use.
During tramadol reduction, pain severity, physical function, withdrawal symptoms, and overall quality of life should be monitored. The reduction would also remove the clinically relevant tramadol–sertraline serotonergic interaction.
Step down proton pump inhibitor therapy
If GERD remains well controlled and there is no compelling indication for chronic high-dose therapy—such as severe erosive oesophagitis, Barrett’s oesophagus, or gastrointestinal bleeding prophylaxis—omeprazole could be stepped down from 20 mg twice daily to 20 mg once daily.
If symptoms remain controlled, further dose reduction or a supervised trial of discontinuation could subsequently be considered. The patient should be counselled regarding possible rebound acid hypersecretion following PPI reduction.
Clarify calcium carbonate use
The indication for calcium carbonate should be established. If it is being used primarily as an antacid, its requirement may decrease following successful GERD management. If it is being used for calcium supplementation or osteoporosis prevention, dietary calcium intake, bone health, and fracture risk should be assessed before discontinuation.
Medication timing should also be reviewed because calcium can reduce levothyroxine absorption when administered too closely together. The two medications should generally be separated by at least four hours.
Reassess vitamin B12 supplementation
The reason for vitamin B12 supplementation should be confirmed through the patient’s history and previous laboratory results. If supplementation was initiated for documented deficiency, pernicious anaemia, malabsorption, or another persistent indication, treatment should continue as appropriate.
If it was initiated for a potentially reversible deficiency associated with prolonged acid suppression, vitamin B12 status could be reassessed after PPI optimization rather than automatically continuing supplementation indefinitely.
Conduct staged follow-up
Deprescribing should occur sequentially rather than discontinuing multiple medications simultaneously, allowing the clinical consequences of each intervention to be evaluated. Follow-up should include assessment of:
- Serum potassium and renal function
- Pain severity and functional capacity
- Tramadol withdrawal symptoms
- GERD recurrence
- Vitamin B12 status when clinically indicated
- Medication adherence and overall pill burden
Clinical Rationale and Ramifications
This case demonstrates how polypharmacy can develop through medication accumulation rather than deliberate prescribing of an excessive number of medications at a single encounter. A medication may remain on the list long after its original indication has disappeared, while treatments added to manage chronic symptoms may continue indefinitely without systematic reassessment.
The continued potassium prescription provides a particularly important example. A supplement that was appropriate during diuretic therapy may become unnecessary—and potentially harmful—after the diuretic is discontinued. In a patient receiving an ACE inhibitor such as lisinopril, unnecessary potassium supplementation may ultimately contribute to clinically significant hyperkalaemia.
Similarly, continuing scheduled tramadol despite stable pain exposes the patient to ongoing opioid-related adverse effects and an avoidable interaction with sertraline. Reducing unnecessary opioid exposure may decrease the risks of sedation, falls, constipation, dependence, seizures, and serotonin toxicity.
Long-term high-intensity PPI therapy should also be periodically reassessed. However, deprescribing omeprazole should not automatically lead to discontinuation of calcium or vitamin B12; each medication requires an independent assessment of indication, benefit, and risk.
A structured deprescribing strategy can therefore reduce medication burden while preserving effective therapies. The central principle is not simply to reduce the number of medications, but to ensure that every medication has a current indication, provides meaningful benefit, and remains safer than the alternatives. In older adults, regular medication reconciliation and staged deprescribing can substantially reduce preventable medication-related harm while improving treatment simplicity and quality of life.