Bastidores da prescrição de inibidores de bomba de prótons: uma pesquisa internacional sobre práticas e conhecimentos médicos / Behind the proton pump inhibitor prescription: an international survey on physician practices and knowledge

ABSTRACT Background: Proton pump inhibitors (PPIs) are widely prescribed worldwide, often resulting in their overuse. Consequently, it is essential to identify the likely causes of this overuse to facilitate their appropriate prescription. Objective: This study aims to assess physician prescribing patterns, their knowledge of PPIs, and factors affecting their knowledge. Methods: An online survey was conducted among Latin American and Spanish physicians, collecting the following data: professional information, patterns of PPI usage, familiarity with published evidence, and the management approach in three hypothetical case-scenarios. Participant knowledge was categorized as sufficient or insufficient based on the results of the case scenarios. Subsequently, subgroup analysis was performed based on physician training level, years in practice, specialty, and time since the last PPI literature review. Results: A total of 371 physicians participated in the survey. Thirty-eight percent frequently prescribe PPIs, primarily for prophylactic purposes (57.9%). Eighty percent were unfamiliar with PPI deprescribing strategies, and 54.4% rarely reviewed the ongoing indication of patients taking a PPI. Sixty-four percent demonstrated sufficient knowledge in the case-scenarios. A significant association was observed between specialty type (medical vs surgical: 69.4% vs 46.8%, P<0.001), the timing of the PPI indication literature review (<5 years vs >5 years: 71.4% vs 58.7%, P=0.010), and sufficient knowledge. Conclusion: While most participants prescribed PPIs regularly and for prophylaxis purposes, the majority were unfamiliar with deprescribing strategies and rarely reviewed ongoing indications. Sufficient knowledge is correlated with recent literature reviews and medical specialty affiliation.

RESUMO Contexto: Os inibidores da bomba de prótons (IBPs) são amplamente prescritos em todo o mundo, muitas vezes resultando em seu uso excessivo. Consequentemente, é essencial identificar as prováveis causas desse uso excessivo para facilitar sua prescrição adequada. Objetivo: Este estudo tem como objetivo avaliar o padrão de prescrição dos médicos, seu conhecimento sobre IBPs e fatores que afetam seu conhecimento. Métodos: Uma pesquisa on-line foi conduzida entre médicos latino-americanos e espanhóis, coletando os seguintes dados: informações profissionais, padrões de uso de IBP, familiaridade com evidências publicadas e abordagem de manejo em três casos-cenários hipotéticos. O conhecimento dos participantes foi categorizado em suficiente ou insuficiente com base nos resultados dos cenários de caso. Posteriormente, a análise de subgrupos foi realizada com base no nível de formação do médico, anos de prática, especialidade e tempo desde a última revisão da literatura dos IBPs. Resultados: Um total de 371 médicos participaram da pesquisa. Trinta e oito por cento prescrevem frequentemente IBP, principalmente para fins profiláticos (57,9%). Oitenta por cento não estavam familiarizados com as estratégias de prescrição de IBP, e 54,4% raramente revisaram a indicação contínua de pacientes em uso de IBP. Sessenta e quatro por cento demonstraram conhecimento suficiente nos cenários-caso. Observou-se associação significativa entre o tipo de especialidade (médica vs cirúrgica: 69,4% vs 46,8%, P<0,001), o momento da revisão da literatura de indicação do IBP (<5 anos vs >5 anos: 71,4% vs 58,7%, P=0,010) e conhecimento suficiente. Conclusão: Embora a maioria dos participantes prescrevesse IBPs regularmente e para fins de profilaxia, no entanto, não estava familiarizada com estratégias de prescrição e raramente revisava as indicações em andamento. O conhecimento suficiente está correlacionado com revisões recentes da literatura e afiliação à especialidade médica.

Deprescripción de medicamentos en pacientes adultos mayores: una revisión de la literatura / Deprescribing medications for elderly patients: a narrative review

Dado el envejecimiento poblacional que vive Chile, se hace cada vez más importante evaluar la seguridad y uso de medicamentos en adultos mayores. Una de las estrategias propuestas a nivel internacional es la deprescripción, que consiste en la disminución o eliminación de fármacos utilizados como tratamiento habitual. Para ello se diseñó esta revisión narrativa que pretendeofrecer un análisis de la literatura de la deprescripción de medicamentos en adultos mayores, con el fin de promover su práctica. Se realizó una búsqueda de artículos publicados entre los años 2003 al 2021, en bases de datos como Science Direct, MEDLINE, TripdataBase y Web of Science, seleccionando aquellos con mayor nivel de evidencia. Según la revisión la deprescripción, en general, se define como un proceso de retirada de la medicación inapropiada, bajo la supervisión de un profesional; siendo su principal causa la presencia de polifarmacia, y la prescripción de medicamentos potencialmente inapropiados. Los principales fármacos deprescritos con éxito (sin necesidad de ser reincorporados) corresponden a benzodiazepinas, antipsicóticos atípicos, corticoides, antidepresivos tricíclicos, estatinas e inhibidores de la bomba de protones. En conclusión: la deprescripción es un proceso poco estudiado, especialmente a nivel local; sin embargo, existe suficiente evidencia que avala la disminución los problemas de salud, en especial los referidos a la seguridad de la farmacoterapia en los adultos mayores.

It is becoming increasingly important to evaluate the safety and use of medications in older people in Chile, given the ageing of its population. Deprescription, which is defined as the reduction or elimination of drugs used by a given patient, is one of the strategies, proposed at the international level, to improve the safety of the pharmacotherapy. For this reason, this narrative review was designed, which aims to offer an analysis of the literature on medication deprescription in older adults, to promote its practice. For this, a search of articles published between 2003 and 2021 was performed in databases such as Science Direct, MEDLINE, TripdataBase, and Web of Science. The articles with the highest level of evidence were selected. It was found that deprescription, in general, is defined as a process of withdrawal of inappropriate drugs under the supervision of a healthcare professional; its leading cause is the presence of polypharmacy and the prescription of potentially problematic medications. The main medicines successfully deprescribed (without reincorporation) were benzodiazepines, atypical antipsychotics, corticosteroids, tricyclic antidepressants, statins, and proton pump inhibitors. In conclusion: deprescription is a poorly studied process, especially at the local level; however, there is sufficient evidence to support the reduction in health problems, especially those related to the safety of pharmacotherapy in the elderly.

Uso práctico de inhibidores de bomba de protones / Practical use of proton pump inhibitors / Uso prático de inibidores da bomba de prótons

Los inhibidores de la bomba de protones (IBP) se encuentran entre los medicamentos más utilizados en el mundo por su bajo costo, extensa prescripción y efectividad. Sin embargo, su uso a largo plazo no es inocuo y aún hay vacíos en el conocimiento del empleo adecuado de estos medicamentos. Por lo tanto, en esta revisión se expone, además de sus propiedades generales, sus verdaderas indicaciones, el uso recomendado a largo plazo y las estrategias para lograr la deprescripción, con el fin de evitar el uso indiscriminado.

Proton pump inhibitors (PPIs) are among the most widely used drugs in the world, due to their low cost, extensive prescription and effectiveness. However, its long-term use is not safe and there are still certain gaps in the knowledge of the proper use of these drugs. Therefore, this review aims to expose their general properties as well as their true indications, the appropriate long-term use and strategies to achieve adequate deprescription of these drugs, seeking to avoid indiscriminate use.

Os inibidores da bomba de prótons (IBP) se encontram entre os medicamentos mais utilizados no mundo pelo seu baixo custo, extensa prescrição e efetividade. Embora, seu uso a longo prazo não é inócuo e ainda há vazios no conhecimento do uso adequado destes medicamentos. Por tanto, nesta revisão se expõe, além das suas propriedades gerais, suas verdadeiras indicações, o uso recomendado ao longo prazo e as estratégias para conseguir a deprescrição, com o fim de evitar o uso indiscriminado.

The process of deprescribing in older adults: a methodological protocol / Processo de desprescrição em idosos: protocolo metodológico

Objective: To report, by means of a methodological protocol, the process of deprescribing implemented in a geriatric psychiatry outpatient clinic of a teaching hospital. Methods: The topic of interest was comprehensively reviewed in the scientific literature. Instruments and tools necessary to develop the protocol were selected, including the Treatment Adherence Measure, Beers criteria, the EURO-FORTA List, the Brazilian Consensus on Potentially Inappropriate Medications for Older Persons, Drugs.com, and deprescribing algorithms. Results: The protocol consists of the following steps: 1) Review: Assess older patients' physical and behavioral status and family context and list all medications used; 2) Analyze: Review patients' drug therapy; 3) Act: Initiate deprescribing (if indicated); 4) Adjust: Discuss patients' expectations, beliefs, and preferences and adjust the prescription to their real possibilities; 5) Monitor: Identify responses to treatment, assess adherence to the deprescribing process, and detect return of symptoms or worsening of the underlying disease. Conclusions: Health care professionals need to work together to provide comprehensive care for older persons. The inclusion of deprescribing in more research groups focused on the geriatric population will increase attention to the safety of pharmacological treatment for older patients.

Objetivo: Relatar como ocorre o processo de desprescrição em um ambulatório de Psiquiatria Geriátrica de um hospital universitário, por meio de um protocolo metodológico. Metodologia: O assunto foi revisado na literatura científica e foram selecionados instrumentos e ferramentas necessários para desenvolver o protocolo, incluindo a Medida de Adesão aos Tratamentos, o Critério de Beers, a Lista Fit for the Aged (EURO-FORTA), o Consenso Brasileiro de Medicamentos Potencialmente Inapropriados para Idosos, Drugs.com e algoritmos de desprescrição. Resultados: O protocolo elaborado é composto das seguintes etapas: 1) revisar: avaliar o estado físico e comportamental e o contexto familiar do idoso e listar todos os medicamentos utilizados; 2) analisar: revisar a farmacoterapia do paciente; 3) agir: iniciar a desprescrição (se tiver indicação); 4) ajustar: pactuar expectativas, crenças e preferências do paciente, adaptando a prescrição às suas reais possibilidades; 5) monitorar: verificar as respostas ao tratamento, avaliar a adesão à desprescrição, detectar ressurgimento dos sintomas ou agravamento da doença de base. Conclusões: Os profissionais da saúde precisam trabalhar em conjunto para proporcionar atenção completa ao idoso. A inserção da desprescrição em mais grupos de pesquisa com o foco na população geriátrica possibilitará maior atenção à segurança dos tratamentos farmacológicos dos pacientes.

Impediments to deprescription in Brazil: overview from a panel of geriatrics experts / Os condicionantes à desprescrição no Brasil: o panorama de um painel de especialistas em geriatria

Objectives: To identify impediments to deprescription among older adults from the perspective of a panel of Brazilian geriatricians. Methods: The Delphi method was used to obtain a consensus among Brazilian geriatricians about the factors that influence the lack of deprescription for older adults in clinical practice. The study was developed in two stages: (i) a survey and description of potential factors involved in deprescription; and (ii) applying the results of the survey to a panel of experts to obtain a consensus. Results: The deprescription process is influenced by the interaction of three pillars of older adult health care: the prescriber, the patient-family, and the health care system. In the professional and health care systems, professional training and communication skills, prolonged clinical follow-up, access to the multidisciplinary team, medical consultations of an adequate time, and unified electronic health records were identified as facilitators of deprescription. In the patient-family pillar, clear facilitators included health literacy, no sensory or cognitive deficits, and a clinical situation of transitional or palliative care. Conclusions: Deprescription is a complex, multifactorial process that requires attention, time, and specific skills and competencies from the attending physician, but it also requires shared decision-making and a health system compatible with a culture of deprescription.

Objetivos: Identificar os fatores condicionantes para a desprescrição em idosos na perspectiva consensual de um grupo de geriatras brasileiros. Metodologia: Foi utilizado o método Delphi para a obtenção de um consenso entre médicos geriatras brasileiros sobre os fatores que condicionam a desprescrição na assistência à saúde do idoso, na prática clínica. O estudo desenvolveu-se em duas etapas: (i) levantamento e descrição dos potenciais fatores envolvidos na prática da desprescrição; e (ii) submissão do levantamento realizado na etapa anterior a um painel de especialistas para a obtenção do consenso. Resultados: O processo de desprescrição é influenciado pela interação de três pilares da assistência à saúde do idoso: o prescritor, o paciente-família e o sistema de saúde. Como elementos de destaque, verificou-se que tanto a capacitação profissional, a habilidade em comunicação e o acompanhamento clínico prolongado do paciente quanto o acesso à equipe multidisciplinar, o tempo adequado para a consulta médica e o registro eletrônico único em saúde foram apontados como facilitadores à desprescrição, conforme os pilares do profissional e do sistema de saúde. Sob o pilar do paciente- família, os facilitadores evidenciados foram a literacia em saúde, a ausência de déficits sensoriais ou cognitivos, a situação clínica de cuidados de transição ou cuidados paliativos. Conclusões: A desprescrição é um processo complexo, multifatorial, que exige atenção, tempo, habilidades e competências específicas do médico assistente, mas requer decisão compartilhada e um sistema de saúde coadunável com a cultura de desprescrever

Proton pump inhibitor deprescription: A rapid review

Abstract Proton pump inhibitors (PPI) are drugs that suppress gastric acid secretion. Its use, without support from scientific evidence, can contribute to polypharmacy, lead to drug interactions and, in the long term, cause serious adverse reactions. Studies advise physicians to deprescribe PPI. A quick review of scientific evidence, also called a rapid systematic review, on the deprescribing of PPI was performed. Evidence searches were performed in the LILACS, Embase, PubMed and NICE evidence databases with the terms "omeprazole", "proton pump inhibitors", "deprescription", "deprescribing". At LILACS these descriptors were also used in Portuguese and Spanish. Of 118 studies identified, four systematic reviews were selected for analysis. Abrupt deprescribing was associated with an increased risk of symptom recurrence. Fear of symptom recurrence is one of the major barriers to patient-related deprescribing. Educational interventions directed at prescribers, pharmacists, and patients are effective strategies in the deprescribing of PPI. Deprescribing process showed to be feasible in different contexts, with different strategies. The process is most effective through actions with educational and guidance materials directed to health professionals and patients, and with the involvement or leadership of the pharmacist.

Deprescribing benzodiazepines: Do Brazilian package inserts address this issue? / Desprescrição de benzodiazepínicos: As bulas brasileiras abordam essa temática?

OBJECTIVE: To analyze the presence and quality of content on drug deprescribing in Brazilian package inserts for benzodiazepine drugs. METHODS: Documentary study where we analyzed data on deprescribing extracted from electronic package inserts of drugs containing benzodiazepines; these documents were available at the Brazilian Health Surveillance Agency website. Our search was performed independently by 2 researchers who used the following keywords: "deprescription," "withdrawal," and "tapering." The deprescribing plan, when presented by the package insert, was compared to deprescribing protocols for benzodiazepines found in the literature. Moreover, we assessed the presence of guidance on the maximum length of treatment and risks of long-term use. RESULTS: We found 12 package inserts for benzodiazepines and 100% of them suggested gradual withdrawal; only 1 (8.33%) suggested a systematized deprescribing plan. One document (8.33%) did not offer guidance on maximum treatment duration. Eleven (91.67%) had the information on long-term use possibly causing dependence or tolerance, and 1 (8.33%) did not describe the risks of continuous use. CONCLUSIONS: It is known that benzodiazepines should be withdrawn in a gradual and schematized manner, but package inserts do not currently bring this information in detail. It is of utmost importance that health professionals be educated on their conduct, hence the necessity for updating medication package inserts.

OBJETIVO: Analisar a presença e a qualidade do conteúdo sobre desprescrição em bulas brasileiras de benzodiazepínicos. METODOLOGIA:Estudo do tipo documental, em que foram analisados dados sobre a desprescrição extraídos de bulas eletrônicas de medicamentos que contêm benzodiazepínicos disponibilizadas na página eletrônica da Agência Nacional de Vigilância Sanitária. A busca foi realizada de forma independente por dois pesquisadores que utilizaram as palavras-chave "desprescrição", "retirada" e "redução". Para fins de comparação, quando a bula apresentou esquema de desprescrição, este foi comparado com protocolos de desprescrição de benzodiazepínicos encontrados na literatura. Além disso, foi analisada nas bulas a existência de orientações quanto ao tempo máximo de uso e os riscos do uso prolongado. RESULTADOS: Foram encontradas 12 bulas de benzodiazepínicos e 100% delas sugeriram a redução gradual do medicamento; apenas uma (8,33%) sugeria o esquema sistematizado de desprescrição. Uma (8,33%) não apresentou orientações quanto ao tempo máximo de uso. Onze (91,67%) continham a informação de que o uso prolongado pode causar dependência ou tolerância e uma (8,33%) não descrevia os riscos do uso contínuo. CONCLUSÕES: Sabe-se que os benzodiazepínicos devem ser retirados de forma gradual e esquematizada, porém, atualmente, as bulas não trazem essas informações de forma detalhada. É de suma importância que os profissionais de saúde sejam orientados quanto a sua conduta e, por isso, há grande necessidade de atualização das bulas.

Deprescripción en el anciano polimedicado. Una mirada reflexiva en el contexto cubano / Deprescription in the polymedicated elderly. A reflexive look at the Cuban context

Introducción: El intervencionismo terapéutico excesivo propicia polifarmacia y errores de prescripción en ancianos. En Cuba, el anciano polimedicado es un problema recurrente; sin embargo, la información sobre deprescripción posee difusión limitada en el ámbito científico. Objetivo: Describir el conocimiento actual sobre deprescripción y la necesidad de una estrategia dirigida al anciano polimedicado en Cuba. Material y Métodos: Se realizó una revisión extendida desde 2003 hasta 2020, basado en la experticia de los autores. Los criterios de búsqueda, selección y el acceso a bases de datos y fuentes indexadas Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, Elsevier permitió citar 54 investigaciones (70 por ciento actualización) y redactar con metodología cualitativa, enfoque histórico-lógico, análisis-síntesis el documento final. Desarrollo: La deprescripción aparece desde 2003 para resolver la polifarmacia, es una herramienta de la prevención cuaternaria, implica desmontaje de medicación con varios matices. Su auge revolucionó diversas corrientes de trabajo en el mundo. Suficientes evidencias científicas de su necesidad y oportunidad para el mejor manejo farmacoterapéutico del anciano justifican un diseño e implementación atendiendo a las determinantes sociales de cada país. Se proponen elementos a la definición, se asevera la importancia de la farmacología geriátrica ante diseños de intervención. Conclusiones: La deprescripción es un proceso inherente de decisiones farmacoterapéuticas en ancianos atendidos en sistemas sanitarios de avanzada. Demuestra reducir mortalidad, medicamentos prescritos y prescripciones inapropiadas. El Programa Nacional de Medicamentos no dispone de directrices para su implementación, por lo que desarrollar una estrategia será un reto para la Salud Pública Cubana(AU)

Introduction: The excessive therapeutic interventionism promotes polypharmacy and prescription errors in the elderly. In Cuba, the polymedicated elderly is a recurrent problem; however, the information about prescription has a limited diffusion in the scientific field. Objective: To describe the current knowledge about deprescription and the need for a strategy aimed at addressing the problem of the polymedicated elderly in Cuba. Material and Methods: An extended review based on the authors' expertise was carried out from 2003 to 2020. The search and selection criteria and the access to databases and sources indexed in Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, and Elsevier allowed us to cite 54 research works (70 percent updated). The final document was written on the basis of qualitative research methodology and historical-logical and analysis-synthesis approaches. Development: The term "deprescription" appeared in 2003 to solve the problem of polypharmacy. It is a quaternary prevention tool that involves dismantling medication treatment with various nuances. Its rise revolutionized different work currents worldwide. Adequate scientific evidences of its need and opportunity for the best pharmacotherapeutic management in the elderly justify a design and implementation that takes into account the social determinants of each country. Some elements are suggested for the definition; the importance of geriatric pharmacology is affirmed in the face of intervention designs. Conclusions: Deprescription is an inherent process of pharmacotherapeutic decisions in elderly patients attended in advanced healthcare systems. It shows a reduction of mortality, prescription of drugs and inappropriate prescriptions. The National Drug Program does not have guidelines for its implementation; therefore, to develop a strategy will be a challenge for the Cuban Public Health(AU)

Optimizando farmacoterapia mediante la deprescripción: reporte de caso / Optimizing pharmacotherapy through deprescription: Case report

RESUMEN La polifarmacia es el uso simultáneo o excesivo de varios medicamentos y ha presentado una tendencia al aumento durante los últimos años, al igual que los cuadros clínicos asociados a interacciones farmacológicas secundarias, llevando así a adicionar cada vez más medicamentos, esto genera el fenómeno de cascada en la prescripción. En este artículo se presenta un caso de una mujer de 34 años, identificado desde una plataforma transaccional de registro de medicamentos prescritos de una EPS, a quien se realizó seguimiento de su tratamiento farmacológico ambulatorio durante 7 meses, en los cuales presentó persistencia de polifarmacia. Se identificó en el caso posibles errores en medicación y posibles ajustes a la terapia que disminuirían el riesgo de interacciones o cascada de prescripción.

SUMMARY Polypharmacy is the simultaneous use or excess of dosage of medicines and it has shown a tendency to increase in recent years, as well as the clinical symptoms associated with secondary drug interactions, thus leading to the addition of more and more medications, generating the cascade phenomenon of prescription. We present a case of a 34-year-old woman, identified from a transactional platform of registration of prescribed drugs of an EPS, who was followed up on her outpatient pharmacological treatment for 7 months, in which she presented persistent polypharmacy. It was identified in the case possible errors in medication and possible adjustments to the therapy that would decrease the risk of interactions or prescription cascade.

A Questionnaire Based Observational Study On Polypharmacy In Elderly People Living In Urban And Rural Areas

Introduction: Polypharmacy is defined as taking more than five drugs per day, every day. Polypharmacy in elderly is becoming more common because of increased number of chronic diseases with which an elderly person suffers given the longer life expectancy in modern times. The major concern about polypharmacy in elderly is prescription cascade. Drug interaction and adverse drug reactions are misinterpreted and misdiagnosed as another health problem. This will lead to one more prescription. Quality of life of an elderly person is compromised with polypharmacy though it prolongs life expectancy. Method: Questionnaire based cross sectional study conducted on both urban and ruralpopulation. Institutional ethics committee permission has been taken. Oral consent has been taken from the subjects and only their information has been used in this study.Subjects aged more than 60 years have been considered for the study. Bed ridden patients, hospitalized patients and elderly people with acute illness were excluded from the study. Results: Data was collected from 134 subjects. Number of subjects: urban participants were 64 and rural participants were 70. Male and female were included. Prevalence of polypharmacy observed in this study was 40% in urban participants and 23% in rural participants. It was observed that, among elderly participants on polypharmacy 75% faced adverse drug reactions and 60% were subjected to prescription cascade. Among the elderly participants taking less than 5 drugs per day, 50% faced adverse drug reactions and 12% were subjected to prescription cascade. Discussion: Adverse drug reactions and prescription cascade are main complications of polypharmacy in elderly people. Prescription review, counseling, life style modification and carefully supervised deprescription are some of the available solutions to solve the complications due to polypharmacy

Luces y sombras de la deprescripción / Lights and shadows of deprescription

La deprescripción es un acto de prevención cuaternaria que pretende evitar, reducir y paliar el perjuicio provocado por intervenciones médicas. El objetivo de este estudio fue conocer los sentimientos, percepciones y actitudes de los pacientes ante la deprescripción de medicamentos y estudios, por parte de médicos de familia/generalistas de un Centro Médico de Atención Primaria. Se realizó un estudio cualitativo de abordaje fenomenológico en pacientes >18 años. Se realizaron 13 entrevistas, analizadas siguiendo la teoría fundamentada. Ante la deprescripción los pacientes deciden buscar una segunda opinión, validan el conocimiento médico según resultados clínicos, y cuestionan las indicaciones recibidas al salir de la consulta. Se enfrenta lo que el paciente trae consigo y demanda con lo que el médico indica. Cuando éste no lo favorece aparecen emociones como angustia, enojo, poniendo en juicio las intervenciones médicas. Se debilita la seguridad en su médico y aparece la desconfianza. Como conclusión, el paciente no adhiere a la deprescripción. Enfatizamos la necesidad de explorar la dolencia del paciente al momento de deprescribir, así como darle valor a su autonomía en la toma de decisiones.

Deprescription is a quaternary preventive action which aims at avoiding, reducing and alleviating the prejudice caused by medical interventions. The objective of this study was to know the patients' feelings, perceptions and attitudes towards deprescrition of medicine and studies of general practitioners/family doctors from a Primary Health Care Center. Qualitative study of phenomenological approach in patients >18 years was carried out. When facing deprescription patients decide to look for a second opinion, ratify medical knowledge according to clinical results, and question the medical indications when they leave the office. What the patient brings and demands what the doctor indicates is dealt with. When not in favor, feelings such as anguish, anger, arise and they judge medical intervention. Trust is weakened and distrust appears. As a conclusion, the patient does not adhere to deprescription. We emphasize the need to explore the patient's disease when deprescription occurs, as well as valuing autonomy in decision taking.