Drug Classes to Deprescribe in Older Persons with HIV in Presence of Certain Conditions

Deprescribing should aim to reduce pill burden, drug toxicities, falls, hospital admission, mortality and improve Health related Quality of Life.

Acetylcholinesterase inhibitors

e.g, donepezil, rivastigmine

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
History of persistent bradycardia (< 60 beats/min), heart block, or recurrent syncope or coadministration of beta-blocker, digoxin, diltiazem, verapamil	Increase the risk of cardiac conduction failure, syncope and injury	Taper gradually, consider halving the dose every 4 weeks

Antipsychotics

e.g., haloperidol, lurasidone, paliperidone, perphenazine

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
Parkinson	Severe extra-pyramidal symptom	quetiapine, clozapine

Aspirin

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
Low cardiovascular risk and/or advanced age and/or high risk of gastrointestinal bleeding (e.g., concurrent use of NSAIDs, SSRIs, corticosteroids) and/or prior gastrointestinal disease and/or coadministration of a second antiplatelet or anticoagulant (continued beyond the recommended duration)	Risk of bleeding	No need to taper

Biphosphonates

e.g., alendronate, ibandronate, risedronate, zoledronate

Conditions for which deprescribing should be considered

Problems caused by drug class

Alternatives or information on how to stop drug

Low risk of fracture or history of 5 years of continuous treatment with a bisphosphonate

Biphosphonates keep showing a benefit in non-vertebral fractures in the 5 years after an initial treatment particularly if the T score is above -2.5. Prolonged use increases the risk of osteonecrosis of the jaw, hypocalcemia and/or severe vitamin D deficiency.

No need to taper

Opioids

e.g, codeine, fentanyl, morphine, oxycodone, tramadol

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
Chronic non-cancer pain	Tolerance to analgesic effect of opioids with long-term use. Associated with adverse psychological effects, higher risk of death from drug overdose with opioids.	Multidisciplinary pain management program. Written and verbal instructions should be provided to patients and families to educate about the tapering protocol that will minimize the withdrawal symptoms

Proton pump inhibitors (PPIs)

e.g, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
Uncomplicated peptic ulcer disease	Long-term use is linked with increased risk of fracture, enteric infections, mineral deficiencies	Use low dose of PPI -> if symptoms well controlled -> use PPI on demand -> if symptoms well controlled -> stop PPI

Selective serotonin re-uptake inhibitors (SSRIs)

e.g., citalopram, fluoxetine, paroxetine, sertraline

Conditions for which deprescribing should be considered	Problems caused by drug class	Alternatives or information on how to stop drug
Current or recent significant hyponatremia (i.e. serum Na+ <130 mmol/L)	Syndrome of inappropriate antidiuretic hormone secretion (SIADH) and aggravation hyponatremia	agomelatine, bupropion, mianserin, trazodone. Note: tricyclic antidepressants should be avoided as associated with a higher risk of adverse effects (e.g., life-threatening arrhythmias and heart block)