TABLE 1.

Short description and elements of the drug discontinuation instruments (sorted by format and author)

Authors	Year	Format a	Name (a), short description (b) and list of elements and questions (as named by instrument; c)
Jansen et al 32	2016	Step‐by‐step (4)	a: “Process for deprescribing with older adults”: b: Narrative description of the deprescribing process in 4 steps with a clear focus on shared‐decision‐making c: Elements: 1) creating awareness that options exist (triggering situations, patients' attitude, cognitive biases, multidisciplinary) 2) discussing options and their benefits and harms 3) exploring patient preferences 4) decision‐making
Reeve et al 16	2014	Step‐by‐step (5)	a: “The 5‐step patient‐centred deprescribing process”: b: ‐ framework of a 5‐step deprescribing process ‐ utilization and integration of existing tools such as Medication Appropriateness Index and Beers list c: Elements: 1) comprehensive medication history 2) identify potentially inappropriate medication (referring to existing tools) 3) determine if medication can be ceased and prioritized 4) plan and initiate withdrawal 5) monitoring, support and documentation
Scott et al 25	2012	Step‐by‐step (10)	a: “A 10‐step drug minimization framework”: b: ‐ 10 sequential steps guiding process of drug discontinuation including medication assessment ‐ caveats and practical instructions are highlighted for each step c: Elements: A: Constructing a patient profile 1) ascertain all current medications 2) identify patients at high risk for adverse drug reactions 3) estimate life expectancy 4) define care goals in the context of life expectancy, disability and priorities B: Making treatment decisions 5) define and confirm current indications 6) determine time until benefit for disease‐modifying medications 7) estimate magnitude of benefit vs harm 8) review relative utility of different drugs 9) identify drugs that may be discontinued C: Monitoring and reviewing treatment decisions 10) implement and monitor a drug minimization plan
Tenni and Dunbabin et al 30	2016	Step‐by‐step (6)	a: “Deprescribing: a personalised approach”: b: ‐ framework of 6 sequential steps in a “deprescribing cycle” ‐ every step comes with a description including drug assessment ‐ beside this general booklet, different medication‐specific brochures were published by same group c: Elements: 1) consider patient (expectations, frailty, life‐expectancy) 2) medication history (what, how long, why, ADR, interactions), 3) identify potential drug targets (risk/benefit [PIM lists], duplicates, poor risk, risky dose etc.) 4) determine cessation priority (least utility, high risk, adverse impact, patient preference, complicated administration) 5) plan and withdraw, 6) monitor, support and document
Woodward et al 34	2003	Step‐by‐step (5)	a: “Deprescribing principles”: b: ‐ narrative sequence of 5 steps describing the ideal deprescribing process ‐ list of medication‐specific recommendations enclosed c: Elements: 1) review all current medications (including indication for use, compliance, ADR) 2) identify medications to be targeted for cessation 3) plan a Deprescribing regimen (best in team, prioritizing drugs) 4) plan in partnership with patient and Carers (shared decision‐making) 5) frequent review and support
Bain et al 20	2008	Algorithm	a: “The prescribing stage revised ‐ discontinuing medications”: b: Integration of medication discontinuation into the traditional medication‐use process algorithm of starting, changing and continuing medication c: Elements: ‐ indication to discontinue medication? ‐ identification and prioritization of medication to discontinue ‐ plan, communicate and coordinate discontinuation ‐ monitor effects
Garfinkel et al 21	2007	Algorithm	a: “Geriatric‐palliative approach for improving drug therapy in disabled elderly people” b: ‐ complex algorithm with a set of questions culminating in stopping, shifting, reducing or continuing drug: c: Elements: ‐ evidence‐based indication and dosing in patient's age group and disability level? ‐ benefit outweighs possible adverse effects in old and disabled patients ‐ indication seems valid (in patient's age group and disability level) ‐ adverse symptoms/signs ‐ alternative superior drugs ‐ dosing reduction without risk
Hardy and Hilmer et al 31	2011	Algorithm	a: “Algorithm for deprescribing in the last year of life”: b: ‐ algorithm with short questions and hints guiding the process of deprescribing with a focus on last year of life c: Elements: ‐ life expectancy and trajectory of decline ‐ goals of care ‐ list of medication ‐ medication assessment (adherence, adverse reaction, indication, interactions) ‐ immediate cessation vs weaning or continuation on optimal dose ‐ follow‐up (adherence, adverse withdrawal effect, re‐emergence of symptoms, goals of care) ‐ repeat process
Jones et al 27	2013	Algorithm	a: “Medication review process” b: ‐ algorithm with questions guiding medication review leading to continuation, dose reduction or stopping of medicine. c: Elements: ‐ evidence‐based indication and dosage in relevant age group? ‐ balance benefits vs potential adverse effects ‐ replacing vital hormone? ‐ preventing rapid symptomatic deterioration? ‐ medicine for resolved condition or without effect? ‐ dose‐reduction without risk? ‐ in doubtful medication, interprofessional collaboration suggested
Meulendijk et al 33	2015	Algorithm	a: “The Systematic Tool to Reduce Inappropriate Prescribing (STRIP)‐Assistant”: b: ‐ integration of the guideline STRIP on polypharmacy (published 2012 in Dutch) with an electronic web‐based processing ‐ web‐application allows automated analysis of data with output to start, stop or alter medication c: Elements: ‐ STRIP refers to 5 steps: Medication history and assessment; pharmacotherapy review; pharmaceutical care plan; shared decision‐making; follow‐up and monitoring ‐ STRIP‐Assistant integrates this information together with data from guidelines on clinical interactions, double medication, contraindication, dosage, frequency, START/STOPP criteria, physical properties
Niehoff et al 23	2016	Algorithm	a: “Tool to Reduce Inappropriate Medications”: b: ‐ built of 2 applications: First application extracts patient data from electronic health record, second application is a set of clinical algorithms for medication evaluation, allowing an automated assessment ‐ finally a patient‐specific medication management feedback report is generated for clinicians c: Elements: ‐ data from health record: Age, chronic conditions, medication, sex ‐ chart review data: body mass index, renal function, diabetic status, blood pressure ‐ patient assessment: medication history, medication adherence, functional status, executive function, life expectancy, review of systems (falls, dizziness, constipation), side effects, management support ‐ evaluation of overtreatment of diabetes/hypertension, PIM, dosing, patient report of problems
Newton et al 22	1994	Algorithm	a: “The geriatric medication algorithm”: b: ‐ algorithm of questions culminating in discontinuing, substituting, dose‐adjusting, changing schedule/preparation of medication or educating patient/caregiver c: Elements: ‐ obtain medication list and orthostatic blood pressure ‐ question indication ‐ risk assessment (high risk drug, aggravating underlying conditions, atypical side effects, orthostatic hypotension, toxicity) ‐ question dosing ‐ look for drug interactions and side effects; simplify drug regimen ‐ consider patient's compliance (unclear regimen, compliance aid needed?)
Poudel et al 24	2016	Algorithm	a: “Algorithm of medication review in frail older people”: b: ‐ based on the identification of high‐risk medication according a newly synthesised list of PIMs ‐ algorithms culminates in continuation, changing or stopping of medication ‐ advice for specific withdrawal regimens and alternative medical and nonmedical management strategies given c: Elements: ‐ identify a high‐risk medication (newly synthesised PIM list); ‐ ascertain current and valid indication (previous trial of discontinuation?) ‐ assess symptomatic benefit and adverse drug events ‐ consider withdrawing, altering or continuing medications
Government of Catalonia, Ministry of Health et al 28	2015	Combination of algorithm and step‐by‐step (3)	a: “Medication management in the complex chronic patient” b: Built of an algorithm for detailed medication assessment (A) and a simple guiding frame of 3 deprescribing stages (B) c: Elements: A. “algorithm for medication clinical review in the complex chronic patient”: ‐ indication ‐ appropriateness (dose, duration, age, renal/hepatic function) ‐ effectiveness (therapeutic objectives) ‐ safety (overlaps, contraindications, drug related problems, prescribing cascade) ‐ Patient's perspective (management and coping, skills, patient's perception of situation) ‐ final advice to withdraw, adjust, replace or continue the drug B. “Deprescription stages”: 1) acknowledge the necessity and situation 2) prepare patient (evaluate patient, negotiate, reach consensus, plan withdrawal, prepare for adverse event) 3) withdraw medicinal product (prioritise, withdraw, evaluate)
Scott et al 26	2015	Combination of algorithm and step‐by‐step (5)	a: “The deprescribing protocol”: b: ‐ five sequential steps for deprescribing ‐ detailed and practical suggestions for every step ‐ integrated medication assessment algorithm culminating in continuing, discontinuing or restarting medication c: Elements: 1) ascertain all drugs and reasons for each 1 2) consider overall risk of drug‐induced harm 3) assess each drug (indication, prescribing cascade, actual or potential harm vs potential benefit, etc.) 4) prioritize drugs for discontinuation 5) implement discontinuation regimen and monitor patients
Starkey et al 29	2015	Set of recommendations	a: “Deprescribing: a practical guide”: b: Loose collections of narrative and listed recommendations on deprescribing c: Elements: ‐ drug assessment (indication, benefit, appropriateness, duration, adherence, prescribing cascade, evidence, treatment goals, ADR, redundancy, changed condition) ‐ stopping/withdrawal regimens (stepwise vs abruptly vs mixed approach) ‐ elaborative description of target population (elderly, frail, vulnerable, housebound patients with multiple drugs and/or shortened life expectancy and fit patients on polypharmacy but lack of indication) ‐ medication review with practical advice ‐ risk/benefit assessment with help of number needed to treat/harm

^aThe instruments' format: algorithm, step‐by‐step approach (number of steps), combinations of algorithm and step‐by‐step approach, narrative set of recommendations.

ADR, adverse drug reaction; PIM, potentially inappropriate medication.