Which Medications Can Be Safely Discontinued?
The medications most commonly appropriate for discontinuation are benzodiazepines, proton pump inhibitors (PPIs), antipsychotics (especially in dementia), cholinesterase inhibitors in advanced dementia, and unnecessary vitamin/herbal supplements—all of which should be tapered gradually rather than stopped abruptly. 1
High-Priority Medications to Consider Discontinuing
Benzodiazepines and Z-drugs (Zolpidem, Zaleplon)
These should be tapered off whenever possible, particularly in older adults, as they cause cognitive impairment, falls with fractures, reduced functional independence, and addiction 1. Long-acting agents like diazepam are especially problematic. Current consensus guidelines recommend benzodiazepines only for short-term use 1. The EMPOWER approach suggests tapering while considering cognitive behavioral therapy as an alternative 1.
Proton Pump Inhibitors (PPIs)
Tapering is more effective than abrupt discontinuation for PPIs prescribed without clear ongoing indication 2. Studies show 14-64% of patients can successfully discontinue PPIs without symptom deterioration when tapered appropriately 2. Guidelines from Ireland (2018) specifically address safe tapering protocols 3.
Antipsychotics in Dementia
These carry an FDA black box warning for increased death risk in dementia patients and should be tapered off when used for behavioral control 1. Both typical agents (chlorpromazine, haloperidol) and atypical agents (quetiapine, risperidone, olanzapine) worsen cognitive function. Canadian and Australian guidelines (2017) provide evidence-based recommendations for safe tapering 3.
Cholinesterase Inhibitors (Donepezil, Galantamine)
Safe to taper off in advanced dementia when there is perceived lack of benefit 1. These medications cause nausea, vomiting, diarrhea, nightmares, and bradyarrhythmias while lacking long-term benefit in advanced disease 1.
Multiple Vitamin/Mineral and Herbal Supplements
These contribute to medication burden without substantiated benefit and can cause drug interactions 1. Glucosamine, turmeric, ginkgo, and many antioxidants have poor to no evidence of pharmacological benefit 1.
Medications Requiring Careful Evaluation
Opioids
Discontinuation should be considered when analgesia and functional independence can be achieved through other interventions 1. Opioids increase risk for addiction, overdose, myocardial infarction, and motor vehicle injury 1. Acetaminophen on a scheduled basis can effectively replace opioids for moderate musculoskeletal pain in elderly patients 1.
Antidepressants
If discontinuation is appropriate, hyperbolic tapering by exponential dose reduction appears most promising for preventing withdrawal symptoms 4, 5. Standard guidelines recommend short tapers of 2-4 weeks, but studies show tapers over months down to doses much lower than therapeutic minimums have greater success 5. The first dose reduction is critical—it must go well 6.
Diabetes Medications in Frail Elderly
Canadian guidelines (2018) address deprescribing in frail older adults (≥65 years) at risk of hypoglycemia 3. Consider dose reduction or discontinuation when HbA1c is very low or when risks outweigh benefits due to frailty 3.
Critical Tapering Principles
Never stop these medications abruptly—withdrawal syndromes can be severe and mistaken for disease relapse 4, 7, 5. The evidence strongly supports:
- Gradual tapering over weeks to months rather than days
- Hyperbolic (exponential) dose reductions rather than linear reductions 4, 5
- Tapering to doses much lower than minimum therapeutic doses before complete cessation 5
- Close monitoring during the first dose reduction—if this goes poorly, slow the taper 6
Common Pitfalls to Avoid
- Mistaking withdrawal for relapse: Patients who deteriorate during guideline-recommended short tapers cannot be assumed to have relapsed—they may be experiencing withdrawal 7
- Inadequate taper duration: 2-4 week tapers show minimal benefit over abrupt discontinuation 5
- Stopping at therapeutic minimum doses: Many patients need tapering to sub-therapeutic doses to avoid withdrawal 5
- Lack of alternative strategies: Before discontinuing benzodiazepines, establish cognitive behavioral therapy; before stopping opioids, ensure scheduled acetaminophen or other non-opioid analgesia 1