Deprescribing Tools in Primary Care: A Critical Review and the Pivotal Role of the Community Pharmacist

Abstract

Introduction: Deprescribing is crucial for improving pharmacotherapeutic safety in polymedicated patients, a common profile in community pharmacy. However, a gap exists between the available evidence and real-world clinical practice.

Objective: This review aimed to identify and critically analyze validated deprescribing tools, assessing their applicability in the community setting and highlighting the leading role the pharmacist can assume.

Material and Methods: A critical narrative review was conducted via a literature search in PubMed/MEDLINE and LILACS, period 2014-2024, using the terms MeSH Deprescribing AND Inappropriate prescription, OR Inappropriate Medicaments. Tools with psychometric and/or clinical validation were included. Two independent reviewers screened studies, and discrepancies were resolved by consensus.

Results: Out of 71 screened studies, 23 were included. We identified 5 updated clinical criteria, 9 specific tools for pharmacological groups, and 9 attitudinal questionnaires. Technical maturity in tools is evident, but critical gaps persist: therapeutic fragmentation, absence of Spanish validation for key instruments, and the exclusion of the community pharmacist from many of them. A key finding is the high willingness to deprescribe among patients (87.6%) and caregivers (74.8%).

Conclusions: We conclude that the community pharmacist, due to their accessibility and holistic view of medication, is the ideal professional to drive deprescribing.

INTRODUCTION

According to the criteria established by the world health organization (who), an individual is considered to have reached older age when they fall within the range of 60 to 74 years, with all persons over 60 years of age generally referred to as older adults or elderly individuals [1]. This population represents a demographic segment that is steadily increasing worldwide; in 2019, it was estimated that there were one billion people aged 60 years or older, and according to projections by the who [2], this figure is expected to rise to 1.4 billion by 2030 and to 2.1 billion by 2050. Within this population group, the phenomenon of polypharmacy—although lacking a universally standardized definition—is most commonly conceptualized as the concurrent use of five or more systemic medications for at least six consecutive months [1].

Within the context of polypharmacy, the concept of potentially inappropriate prescribing (pip) emerges, referring to medications for which the associated risk of adverse events outweighs the expected clinical benefit derived from their use. This situation is particularly relevant when alternative therapeutic options are available that demonstrate a more favorable safety profile or greater efficacy [3].

To identify and assess potentially inappropriate prescribing, methodologies have been developed that are classified as implicit and explicit. Implicit methods, which rely on clinical judgment, are costly and require highly trained personnel—such as clinical pharmacists—to conduct an individualized evaluation of each prescription prior to medication dispensing. In contrast, explicit methods consist of standardized tools, often based on consensus criteria, that can be applied systematically and continuously during the prescribing process itself [4].

In this context, deprescribing has emerged as a fundamental, patient-centered healthcare process. This approach encompasses two key dimensions: on the one hand, the systematic and comprehensive review of all medications with the aim of modifying doses, substituting, discontinuing, or, where appropriate, adding drugs; and on the other hand, the gradual reduction or deliberate and safe discontinuation of treatments that are no longer necessary or whose risk–benefit profile is unfavorable. In this process, primary health care constitutes the central axis, with family physicians and nursing staff being the most appropriate and primary actors for its effective implementation [5–8].

Accordingly, the present study is conducted with the aim of identifying and critically analyzing validated deprescribing tools, assessing their applicability in the community setting, and highlighting the key role that the pharmacist can assume in this process.

MATERIALS AND METHODS

This study was based on a critical narrative review with a semi-structured search, aimed at identifying and rigorously analyzing the scientific literature published between 2014 and 2024. The bibliographic search strategy was conducted in two of the most relevant databases in the health sciences: PubMed/MEDLINE and LILACS (Latin American and Caribbean Health Sciences Literature).

To ensure precision and retrieval of relevant studies, a combination of controlled vocabulary terms (MeSH, Medical Subject Headings) and free-text terms was used. The main search strategy was built around the key descriptor deprescribing combined with the Boolean operators AND (inappropriate prescribing OR inappropriate medication).

The main search equation for PubMed/MEDLINE was as follows: (deprescribing [MeSH] OR deprescribing [Title/Abstract]) AND (inappropriate prescribing [MeSH] OR potentially inappropriate medication list [MeSH] OR inappropriate prescription [Title/Abstract] OR potentially inappropriate medication [Title/Abstract]).

For LILACS, a conceptually equivalent strategy was used with DeCS (Health Sciences Descriptors) and the corresponding Spanish terms, applying the relevant publication year filter: (deprescripción) AND ((prescripción inapropiada OR medicación inapropiada potencialmente OR medicamento inapropiado potencialmente)).

Selection Criteria and Screening Process

Inclusion and exclusion criteria were established to ensure the selection of methodologically high-quality literature. Original research articles, systematic reviews, and validation studies describing tools or explicit criteria for identifying inappropriate prescribing or guiding deprescribing were included. Articles that did not meet these requirements were excluded, as were editorials, letters to the editor, and case reports.

The following specific inclusion criteria were applied:

• Tools or criteria that had been validated from a psychometric perspective (reliability, validity) and/or clinically, in at least one of these two dimensions.

• Instruments under development with preliminary evidence of clinical usefulness or quantitative data on their effectiveness or impact on health outcomes.

• Articles providing relevant quantitative or qualitative data on the applicability of the instruments.

To promote a global perspective and minimize language bias, no language restrictions were imposed, provided that the abstract and full text were available in English or Spanish—languages prevalent in the biomedical literature and accessible to the research team.

The study selection process was conducted systematically and sequentially to manage the volume of results. First, titles of all articles identified through the searches were reviewed. Subsequently, abstracts of potentially relevant articles were examined. Finally, the full texts of preselected manuscripts were read and thoroughly assessed to confirm eligibility according to the established criteria.

Quality Assurance in Study Selection

To ensure objectivity and consistency and to minimize the risk of selection bias, the review of search results and the application of inclusion and exclusion criteria were performed independently and in parallel by two investigators. Discrepancies arising at any stage of screening (title, abstract, or full text) were resolved through discussion and consensus between the two reviewers, with a third investigator acting as an adjudicator when necessary to reach a final decision.

Priority was given to the inclusion of validated tools; however, it was also considered relevant to include instruments that presented partial validation or were in early stages of development when they represented significant conceptual contributions or addressed specific gaps in the literature, in order to provide a comprehensive overview of the current assessment landscape. In all cases, the validation status of each tool is explicitly specified in the corresponding table to ensure transparency.

RESULTS

The screening process identified 71 studies, of which 23 met the inclusion criteria. Figure 1 presents the flow diagram of the selection process, while Table 1 provides a complete and organized list of all included studies, grouped into the three analytical categories. This overall view highlights the scope of the review, which identified 5 updated clinical criteria, 9 tools specific to pharmacological groups, and 9 attitudinal questionnaires. The specific details and comparative characteristics of the attitudinal questionnaires are presented in Table 2.

Figure 1. PRISMA diagram adapted from the study selection process flow chart.

Table 1. List of studies included in the review.

Given that attitudinal questionnaires represent a methodologically mature category with particular relevance for clinical practice in community pharmacy, a detailed comparative analysis of their characteristics was conducted. Table 2 presents a detailed overview of the properties of the nine identified questionnaires (six for patients/caregivers and three for healthcare professionals).

Table 2. Comparative Table of Deprescribing Questionnaires.

DISCUSSION

The results describe a field undergoing methodological consolidation, in which progress in standardized instruments contrasts with gaps that hinder their widespread implementation. Deficiencies are observed in validation, systemic integration, and practical applicability. In this context, the community pharmacist emerges as the professional best positioned to detect polypharmacy, inappropriate medications, and adverse events, moving beyond a traditional role toward a proactive function in therapeutic optimization.

Regarding the updating of clinical criteria, fundamental tools such as Beers 2023 [9], STOPP/START 2023 [10], and PRISCUS 2023 [11] have incorporated recent evidence on frailty and chronicity, thereby improving their applicability in geriatric care. STOPPFrail 2020 [12] specifically facilitates decision-making in palliative contexts. In parallel, the LESS-CHRON 2022 criteria [13] have emerged as a comprehensive alternative, specifically designed for polymedicated patients with multimorbidity, thus addressing limitations of other systems.

In the area of drug-specific tools, low-cost and highly applicable strategies have been identified. Interventions such as Benzocarta 2020 [18] and IBP-carta 2022 [19] represent practical resources enabling pharmacists to initiate deprescribing. These are complemented by evidence-based guidelines for antihyperglycemic agents [14], proton pump inhibitors [15], antipsychotics [16], and benzodiazepines [17], which serve as supporting materials to substantiate recommendations in high-risk pharmacological groups.

However, this approach presents a structural limitation: therapeutic fragmentation. Current tools predominantly focus on individual medications, without adequately addressing geriatric polypharmacy involving multiple concurrent conditions. This disparity underscores the need for professionals with a comprehensive view of medication use, capable of integrating these fragmented tools into coherent therapeutic plans.

In addition, a critical omission is evident: the absence of validated protocols for simultaneous deprescribing in specific geriatric syndromes, such as falls or cognitive impairment, in which multiple medications may be contributing to the clinical problem.

A notable advance lies in the consolidation of attitudinal instruments. The rPATD questionnaire [25] has been established as the global reference standard, with six linguistic validations (Spanish [32], French [33], Portuguese [34], Romanian [35]) and transcultural adaptations for vulnerable populations [36–37], such as patients with cognitive impairment in Arabic [36] and those with limited life expectancy in Danish [37], demonstrating strong methodological robustness. Its benzodiazepine-specific version [38] exemplifies its flexibility of application. Although coexistence with other instruments such as the BMQ [23] and PPoD [26] enriches the methodological landscape, the rPATD [25] maintains leadership in practical use. Nevertheless, even this advanced tool omits relevant dimensions such as socioeconomic impact, distrust of healthcare systems, and the crucial role of informal caregivers in therapeutic adherence.

There is a high willingness among patients and caregivers to accept deprescribing when it is recommended by a trusted professional. A meta-analysis reported that 87.6% of patients and 74.8% of caregivers would be willing to deprescribe [38], findings confirmed by Weir et al. [39], who reported similar figures (84% and 80%, respectively). This favorable attitude represents an underutilized opportunity for healthcare systems, due to the structural barriers previously identified.

Nevertheless, significant validation gaps persist. Key instruments such as the PACPD-12 [30] have not been adapted into Spanish, limiting their use in Ibero-America and marginalizing nursing professionals and community pharmacists, who are essential for adherence and follow-up. Likewise, the strategy for deprescribing statins [21] remains only a study protocol, and the questionnaire for benzodiazepine dispensing [31] is still a prototype without psychometric validation, limiting the evidence base for pharmaceutical action. Furthermore, the coexistence of STOPPFrail version 1 in Spanish [40] and version 2 in English [12] generates confusion in clinical practice.

The Cuban context reflects this global disconnect. National studies on deprescribing are scarce and largely limited to describing current knowledge or polypharmacy in general [41,42]. A recent study by our research team [43] demonstrated that, although the procedure is scarcely studied in Cuba, its application tangibly improves pharmacotherapeutic safety in older adults, highlighting the urgency of its implementation.

Therefore, to bridge these gaps and transform deprescribing into an effective practice, the following actions are recommended: (1) the development of multidrug tools with integrated protocols for geriatric syndromes; (2) the urgent validation into Spanish of key instruments such as PACPD-12 [30], LESS-CHRON 2022 [13], and the full PPoD [26]; and (3) the creation and validation of interprofessional questionnaires that include the perspectives of nursing staff and community pharmacists.

CONCLUSIONS

In conclusion, this review confirms that although mature technical tools for deprescribing are available, their implementation is limited by fragmented guidelines, validation gaps, and an exclusionary professional approach. Owing to their accessibility and comprehensive view of pharmacotherapy, community pharmacists are ideally positioned to lead this process.

To realize this potential, the following actions are recommended: (1) training in the use of explicit criteria; (2) implementation of practical tools such as Benzocarta; (3) use of the rPATD to enhance communication; (4) validation of instruments in Spanish and advocacy for the formal recognition of the pharmacist’s role; and (5) promotion of leadership by community pharmacists in medication optimization.