Deprescribing needs to be considered in the pharmacists’ prescribing role

To the Editor: Pharmacist prescribing rights in Australia have recently sparked debate between medical practitioners and pharmacists.1 While discussion on the potential role of pharmacists to prescribe is important, the debate has focused on the initiation of medications. There is a need to acknowledge that prescribing is a process, which, according to the World Health Organization's six‐step Guide to good prescribing, includes “Step 6: Monitor (and stop?) the treatment”.2 Given inappropriate polypharmacy is increasing in older people,3 collaborative deprescribing (defined as the supervised withdrawal of inappropriate medications) with pharmacists, medical practitioners, and patients should therefore be given equal priority within this debate.

Expanding the pharmacists’ role to deprescribe in collaboration with the medical practitioner can be considered as an effective mechanism to enact Step 6. Pharmacists are experts in pharmacotherapy, and consistently use a collaborative approach in providing health care. There is growing evidence internationally of the effectiveness of pharmacist prescribing roles that include medication cessation. In New Zealand and the United Kingdom, recent changes in the legislation have enabled suitably trained pharmacists to prescribe, and various studies have tested the feasibility of pharmacists initiating and deprescribing medications in multiple settings, such as nursing homes and general practice.4,5

The pharmacists’ expanded deprescribing role can be achievable with a team‐based approach in which there is a clear delineation of roles and responsibilities, separating the prescribing from the dispensing pharmacist, as in New Zealand.5,6 In Australia, many health practitioners can prescribe medications. For example, nurse practitioners can initiate and deprescribe within the boundaries of legislation and scope; that is, limited by the scope of practice, requirements from the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, and by relevant hospital formulary or prescribing arrangements. This may be a model to adopt for expanding the pharmacists’ collaborative deprescribing role.

All the steps that underpin prescribing (initiation to withdrawal) are equally important to ensure patient safety, so they receive appropriate medications that are safe and effective. The proposal of expanding the pharmacists’ prescribing role needs to encompass all aspects of the prescribing process. If initiation and continuation of a medication is emphasised, in the context of pharmacists’ prescribing rights in Australia, we may lose focus on patient care and safety.