Healthcare systems are increasingly faced with ageing populations and rising multimorbidity, but polypharmacy is complicating safe and effective patient care. Gerry Hughes explores this landscape and how DIAMOND – a new research programme using real-world data to support deprescribing – hopes to support clinicians and other healthcare professionals to make positive changes for patients.

Deprescribing is defined as a ‘process of withdrawal of an inappropriate medication, supervised by a healthcare professional with the goal of managing polypharmacy and improving outcomes’. Such an approach presents myriad opportunities to reduce adverse drug events, improve adherence and ensure treatment regimens align with patient goals.

For Dr Dan Ryan, consultant geriatrician and stroke physician at Tallaght University Hospital in Dublin, Ireland, it’s important to acknowledge the risks of polypharmacy, particularly in the older population.

‘Missing an opportunity to deprescribe may lead to adverse outcomes. Polypharmacy reduces compliance with essential agents such as anticoagulants,’ he says. ‘Falls, fatigue and gastrointestinal issues are all common occurrences of excess medication.’

With this in mind, it’s clear that polypharmacy is a global and public health concern. Indeed, the World Health Organization has identified it as a strategic priority through its Medication Without Harm initiative.

Deprescribing is increasingly being researched as an evidence-based approach to tackling this issue. However, Dr Ryan highlights some issues with translating such research to practice.

These include medicolegal fears around stopping a potentially preventative agent, a lack of knowledge among resident or junior doctors around medication risk-benefit ratios, and limited applicability of clinical trial results in which elderly and frail cohorts may have been excluded.

A recent umbrella review , including 12 systematic reviews investigated for the first time the effect and safety of deprescribing across various healthcare setting settings. Evaluating 231 randomised controlled trials (RCTs) and about 50,000 patients, conflicting evidence emerged, with varying levels of certainty of evidence. While deprescribing was found to address potentially inappropriate prescribing, it was not more effective than standard care in preventing community-based patient falls.

However, in nursing homes, deprescribing was associated with less potentially inappropriate medications than standard care and in end-of-life situations, deprescribing significantly reduced mortality.

DIAMOND deprescribing research

DIAMOND, or Developing Innovative Analytical Methods for research ON Deprescribing, seeks to better develop the evidence base on deprescribing. Funded through a €2.4m Wellcome Career Development Award, it is an eight-year programme led by Professor Frank Moriarty, associate professor at the School of Pharmacy and Biomolecular Sciences and institutional lead for open research at the Royal College of Surgeons in Ireland. Its ambition of the programme is to create tools, data resources, and guidance that support both research and clinical practice.

Reflecting on the existing challenges and evidence base around deprescribing, Professor Moriarty says: ‘First, deprescribing often doesn’t happen in practice, partly because we lack data on its effects, both good and bad. The second gap was that methods for analysing real-world interventions hadn’t yet been applied to deprescribing.’

While RCTs are considered the gold-standard for evaluating interventions, the lag time from research to practice and difficulties around applicability of findings to heterogeneous patient cohorts make such studies challenging.

Research using real-world data from such sources as electronic health records and claims databases may provide an alternative discovery route.

DIAMOND aims to be innovative by focusing on three key priorities:

  1. Characterising deprescribing in practice: Mapping how deprescribing is defined across studies and validating these against benzodiazepines, low-dose aspirin and selective serotonin reuptake inhibitors (SSRIs)
  2. Applying target trial emulation: Using synthetic datasets to focus on outcomes such as bleeding and mortality
  3. Mapping serotonergic burden: Developing an index to predict risk of serotonin syndrome and testing how deprescribing SSRIs may influence patient outcomes.

Dr Ryan believes that applying such research to real world settings and leveraging electronic healthcare has the potential to help clinicians to optimise their practice.

‘This can only be a good thing,’ he says. ‘As a geriatrician, I frequently encounter polypharmacy and medication-related hospital admissions. Unambiguous prompting with clear instructions will empower trainee doctors to remove unnecessary agents that carry more harm than benefit.’

Multidisciplinary, patient-centred collaboration

DIAMOND brings together an international consortium of clinical, methodological and digital health experts from Ireland, the UK, Canada, Spain and beyond. This diversity aims to ensure that the interventions developed will be co-produced and generalisable.

‘These perspectives will hopefully help to increase the impact of the programme,’ says Professor Moriarty.

Importantly, deprescribing is not a task for one profession alone. Physicians, pharmacists, nurses and data scientists will likely have connected roles to play in embedding deprescribing into routine care in the future.

Advanced technology and research innovations are important to build much needed evidence in this area. Crucially, though, deprescribing must also be framed as a proactive, patient-centred act – one that places shared decision-making and patient preferences at the heart of care, alongside clinical outcomes.

Dr Ryan advocates for such collaborative, shared decision-making with patients, informed about the true benefit of medications. He says this would enable deprescribing to a greater degree.

‘Get to know the real benefits from these medications and the evidence base; then have an informed conversation with patient and family and deprescribe,’ he advises.

Indeed, the existing literature highlights that future work needs to be done around intervention and implementation components that enhance effectiveness, such as patient-centred elements.

Real-world application of DIAMOND

A central feature of the DIAMOND programme is its commitment to open science. All methods, code and data resources will be made available to ensure transparency and adoption across healthcare systems. Planned outputs include user-friendly R packages and structured risk indices to guide clinical decisions.

Dr Ryan advocates for applying such evidence in a practical way. ‘Embed deprescribing as a core duty in your role as a doctor, especially in older frailer patients in whom medications may be less effective and carry more side effects,’ he says. ‘Make use of the deprescribing evidence base and electronic tools where they are available.’

Indeed, since launching earlier this year, the DIAMOND team has already produced four research protocols describing the breadth of their planned work:

Deprescribing could be considered as a form of medication stewardship, bringing precision to prescribing practice. The DIAMOND programme is designed to make that kind of precision possible, integrating real-world data with advanced analytics to tackle one of healthcare’s most stubborn problems.