Alternative & Non-Prescription Medicines: A Practical Guide

Return to Book Page. A Practical Guide by Christina Bunce ,. Drugs have played a major role in medical treatment for thousands of years. Most of us have taken, or will take, medicines at some time in our lives to cure, prevent, delay or mask the symptoms of ill health.

Clear Drugs have played a major role in medical treatment for thousands of years. Clear and simple to use, it provides information about many of the best remedies commonly prescribed for both adults and children. It offers a range of conventional and alternative approaches to treating many common conditions. It also looks at the known and possible side effects and uses for the medicines most frequently taken at home. Check whether there is still an indication for the use of the medicine and if so, that its use is still consistent with recommendations in current guidelines.

Consider if there are more up-to-date drugs on the market that may be superior and safer. Check if the patient is taking all of their prescribed medicines. If not, ask them why? Did they understand the aims of treatment and did they experience any adverse effects?

If the patient has remained well without the medicine, and is unlikely to suffer harm if it is not taken, consider stopping it e. When a patient presents with new symptoms, consider an adverse medicine reaction as a possible cause. The aim is to avoid the prescribing cascade where additional medicines are initiated to treat adverse effects both recognised and unrecognised of other medicines. For some classes of medicine e. Recognise the need to stop a medicine When the patient presents for a renewal of medicine ask if they have any new symptoms including adverse effects or any concerns about their medicine.

Has the clinical condition of the patient changed? Consider the preferences of the patient. Are there drugs that can be stopped?

Alternative & Non-Prescription Medicines: A Practical Guide

If more than one medicine can be stopped, which one should be stopped first? This relies on clinical judgement and consideration of factors such as medicines most likely to cause adverse effects or without clear indications. Reduce or stop one medicine at a time Try to reduce or stop only one medicine at one time.

• Managing medicines in older people.
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If problems develop it is then easier to know what the likely cause may be. Taper medicines when appropriate To reduce the likelihood of an adverse withdrawal event, many medicines should be tapered. It can be difficult to determine which can just be stopped and which should be tapered. Therefore if in doubt taper, as it is safer. For many medicines the first step in tapering is to halve the dose.

Generally there will be plenty of time to taper a medicine. If the medicine is being discontinued because toxicity is a concern, then a more ambitious taper can be undertaken or the medicine stopped abruptly. Once tapering has begun, ask the patient to note any symptoms that may suggest a more gradual withdrawal is required e. If intolerable symptoms occur following a decrease in the dose or after the medicine has been stopped, then it may be necessary to restart the previously prescribed dose and then try tapering again, but at a more gradual rate.

BPJ Managing medicines in older people

Check for benefit or harm after each medicine has been stopped Ask the patient if any changes have occurred after a medicine has been stopped. Beneficial effects should be noted to reinforce that the decision to reduce or stop the medicine was correct. There is also evidence that the beneficial effects of some medicines may persist even after the medicine is stopped e.

If symptoms of the initial condition return and are troublesome, despite gradual tapering, then it may be that the medicine cannot be stopped completely. The patient may however be able to be managed on a reduced dose e. Antidepressants should be tapered rather than stopped abruptly, to reduce the risk of developing a discontinuation syndrome and to allow time to assess the possible re-emergence of depressive symptoms Table 1.

Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug. Antidepressants should normally be withdrawn over at least a four week period. Patients may experience withdrawal symptoms but usually these are mild and self-limiting. If these symptoms are not tolerated, it may be necessary to resume the previous dose and then reduce the antidepressant more slowly. Regular and prolonged use of hypnotics should be avoided because of the risk of tolerance to effects, dependence and an increased risk of adverse events.

Patients who have taken benzodiazepines on a long term basis should be withdrawn gradually over a number of months e. The longer a patient has been taking a benzodiazepine, the more likely they are to develop dependence and tolerance. There are a wide range of withdrawal symptoms Table 2 and some may be similar to those for which the benzodiazepine was originally prescribed. Some patients may experience withdrawal symptoms such as rebound insomnia and anxiety after only two to four weeks of treatment.

Withdrawal symptoms can continue for weeks or months after stopping a benzodiazepine. Abrupt withdrawal may result in confusion, toxic psychosis, seizures or a condition termed benzodiazepine withdrawal syndrome which is similar to delirium tremens. Benzodiazepine withdrawal syndrome can occur within one day of stopping a short-acting benzodiazepine or up to three weeks after stopping a long-acting benzodiazepine. Successful discontinuation may result in improvements in cognitive and psychomotor function, particularly in older people.

Patients may be more alert and have increased working memory, reaction times and balance. Beta-blockers are the cardiovascular medicine most often associated with adverse withdrawal events. Abrupt withdrawal may cause rebound hypertension, tachycardia, arrhythmia or angina. These events may be physiological withdrawal reactions or an exacerbation of the underlying condition. The decision to stop a statin is based on an assessment of individual benefits and risks. For example, stopping may be justified in a person at relatively low risk of a cardiovascular event, who is also poorly compliant or experiencing troublesome adverse effects.

In most cases statins can be stopped without the need for tapering. Statins should not be stopped in patients admitted with or with a history of cardiovascular events including acute coronary syndrome, myocardial infarction and stroke. In older people taking warfarin, low initial and maintenance dosages are recommended e.

Some clinicians tail off long-term treatment over several weeks but the need for this is unclear. It is possible to stop abruptly rather than taper Table 4. Risks associated with NSAIDs usually relate to declining renal function in the older age group and adverse gastrointestinal effects. NSAIDs may also reduce the effectiveness of antihypertensive therapy. Some patients may tolerate abrupt discontinuation but tapering the dose allows for other analgesics to be introduced or increased Table 5. Many people remain on acid suppressants despite there being no ongoing clinical indication e.

It is often possible to maintain symptom control on a lower dose or on an as needed basis rather than on long term high dose maintenance therapy. Tapering the dose of an acid suppressant both PPIs and H 2 RAs is recommended because of the risk of rebound hypersecretion of gastric acid Table 6. Following discontinuance of omeprazole therapy, gastric acid secretion returns to baseline over a three to five day period. The beneficial effects e. Beneficial effects on BMD persist after stopping the drug. For correspondence regarding stopping alendronate therapy, see "Correspondence: Guidance for stopping alendronate" , BPJ 46 September, Tapering may not be required for some patients who have received low to moderate doses e.

Withdrawal should not be abrupt for the majority of patients who have been taking systemic corticosteroids for more than three weeks. These patients should generally have their corticosteroid slowly tapered to allow the HPA axis to recover over weeks or months. An increase in dose may also be required during periods of stress e. There are several methods for tapering oral corticosteroids Table 7.

The majority of patients respond initially to levodopa and its use improves the quality of life. After two years or more, benefit is reduced as the disease progresses and late complications emerge. If antiparkinsonian drug therapy is reduced abruptly, or discontinued, a symptom complex resembling neuroleptic malignant syndrome can occur Table 8. Follow us on facebook. Login to my bpac. A practical guide to stopping medicines in older people The majority of older people who require drug therapy take multiple medicines. In this article Polypharmacy increases the risk of adverse effects and medicine interactions How do you decide which medicines can be stopped?

What are the likely consequences of stopping medicines? How to stop medicines Specific guidance on stopping medicines References In this article. Key concepts The majority of older people who require drug therapy take multiple medicines Withdrawing medicines may be the best clinical decision Factors to consider when deciding if a medicine can be stopped include the wishes of the patient, clinical indication and benefit, appropriateness, duration of use, adherence and the prescribing cascade Only stop or reduce one medicine at a time Tapering the dose helps reduce the likelihood of an adverse withdrawal event.

Polypharmacy increases the risk of adverse effects and medicine interactions The majority of older people have more than one medical condition, more than one prescriber and take more than one medicine. How do you decide which medicines can be stopped? Factors to consider when deciding if a medicine can be stopped include: The wishes of the patient Clinical indication and benefit Appropriateness Duration of use Adherence The prescribing cascade. Medicines can be grouped as: Those that keep the patient well and improve day-to-day quality of life e. In some cases, if these medicines are stopped, the patient may become ill or unable to function.

However, some drugs may be able to be stepped down, stopped or used on an as required basis prn e. Those that are used for the prevention of illness in the future e. A decision about whether to stop medicines such as these should include consideration of the risks and benefits of treatment for that particular patient, the length of time required for benefit and the life expectancy of the patient.

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The wishes of the patient The majority of people who take medicines would prefer not to, or at least to take only those that are really needed. Clinical indication Check that there is still a valid clinical indication and ongoing clinical benefit for each medicine. Appropriateness Check that the medicine is appropriate for use in an older person see below. Anxiety Relief in One Day. Healing Secrets of the Native Americans. The Touch of Healing. The Way of Herbs. Beginner's Guide to Aromatherapy and Essential Oils. Reverse Gut Diseases Naturally. The Healing Power of Mind.

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