The numbers on medication burden are striking. In the Saudi National Survey for Elderly Health, 51.5 percent of 2,946 community-dwelling older adults were taking five or more therapeutic classes—the common definition of polypharmacy. Across Saudi studies, polypharmacy prevalence ranges from 34 to 76 percent, and potentially inappropriate medications from 43 to 80 percent, depending on setting and definitions. The stakes are not abstract: adverse drug reactions account for an estimated 8.7 percent of hospital admissions among older adults, and polypharmacy is linked to falls, cognitive impairment, hospitalization, and higher healthcare spending. Yet medication count alone does not determine whether a regimen is appropriate—a complex regimen may be fully justified, while a shorter one can still contain a drug whose likely harm outweighs its benefit.

Enter deprescribing: a planned, supervised process of reducing or stopping medications that no longer fit a patient’s treatment goals or benefit–harm balance. Researchers emphasize that it is not the withdrawal of care but a continuous part of good prescribing, revisited as health status, priorities, and treatment burden change. The classic five-step framework—establish the complete medication list, assess overall medication-related harm, weigh each drug’s benefits and harms, prioritize what to stop, and implement with follow-up—has gained international backing through the World Health Organization’s Medication Without Harm challenge. But deprescribing carries its own risks: symptom recurrence, disease relapse, physiological withdrawal effects, and patient anxiety can all follow cessation, which is why tapering and active monitoring are built into the intervention rather than treated as afterthoughts.

Pharmacists sit at the center of this effort for a structural reason: they see the whole regimen across diseases and care settings, not just one condition. Repeated community-pharmacy contact lets them discuss prescription and nonprescription drugs alike, while home medication inventories have shown that older adults often possess over-the-counter products that never appear in the electronic record. The usual workflow starts with a Best Possible Medication History checked against records, followed by a structured review of indication, duplication, benefit–harm balance, and patient goals. The hard part often comes after the review. Among non-hospitalized older adults, acceptance of pharmacist recommendations ranged from 42 to 93 percent, but actual implementation ranged from just 27 to 88 percent. A recommendation without a named prescriber, a route to modify the prescription, and clear responsibility for monitoring is unlikely to change anything.

When the full pathway is implemented, the results can be dramatic. In the Canadian D-PRESCRIBE trial, 489 older adults across 69 community pharmacies received pharmacist-led education plus a pharmaceutical opinion sent to their prescriber; 43 percent discontinued the targeted medication compared with 12 percent under usual care. The EMPOWER study showed that even a patient-directed brochure prompted 27 percent of long-term benzodiazepine users to quit, versus 5 percent with usual care. The hospital-initiated Shed-MEDS program, continued through post-acute care, produced 14 percent fewer medications at discharge and 15 percent fewer at 90 days. But here is the uncomfortable truth the evidence reveals: deprescribing interventions change medication counts far more consistently than they change how patients actually function or feel. A recent systematic review found moderate-certainty evidence for only a small reduction—roughly one fewer medication per seven patients treated—and no significant reduction in the proportion with at least one potentially inappropriate medication. Mortality, hospitalization, and quality-of-life findings remain inconsistent, largely because trials are underpowered and follow-up is short.

The tools pharmacists use to spot problematic prescriptions come in two flavors. Explicit tools like the American Geriatrics Society Beers Criteria and the European STOPP/START criteria apply predefined rules that can be readily built into electronic health systems. Implicit tools like the Medication Appropriateness Index require clinicians to judge each medication against ten criteria—indication, effectiveness, dosage, interactions, duration, cost, and more—offering nuance at the price of time. Both families have a problem in Saudi Arabia: neither has a validated Arabic adaptation, and both were built on American or European evidence and formularies that may not match medications registered by the Saudi Food and Drug Authority. Moreover, explicit tools generally offer limited guidance on tapering or managing withdrawal, and different tools can classify the same medication differently. They identify candidates for review; they do not constitute a deprescribing plan, which must still account for frailty, comorbidities, patient preferences, and goals of care.

Pharmacist authority varies enormously worldwide, and this determines what is actually possible. In England, clinical pharmacists are embedded in general practice and qualified independent prescribers can alter treatment without separate authorization for each change. In the United States, collaborative practice agreements can delegate defined medication-management functions within state law. Canada’s RxACTION study showed community pharmacist prescribing improved blood pressure control, though it addressed hypertension rather than deprescribing. Saudi Arabia currently lacks this clarity: pharmacists there report adequate knowledge and positive attitudes but identify limited training, time, and authority as key barriers. Without defined authority, a pharmacist can identify a deprescribing candidate but cannot prescribe, monitor, or own the change.

Saudi intervention evidence remains thin. Only one small ambulatory-care pilot has tested a deprescribing intervention; most published studies are attitudinal surveys of healthcare professionals’ knowledge and readiness. No Saudi study has evaluated economic or patient-reported outcomes, and long-term effectiveness has never been assessed. Reported barriers include limited consultation time, heavy clinical workload, fear of withdrawal symptoms, absence of a national framework, and unclear institutional guidance. Willingness is not the problem—international evidence suggests many patients will consider deprescribing when a trusted professional recommends it. The gap is between attitude and infrastructure.

Paradoxically, Saudi Arabia’s digital health transformation may be the opening deprescribing advocates have been waiting for. NPHIES, launched in 2022 by the Council of Health Insurance, aims to unify health records across private and government sectors, potentially reducing fragmentation and letting providers review a patient’s complete medication list with standardized coding. Wasfaty, the Ministry of Health’s e-prescription platform introduced in 2019, connects primary care centers and hospitals with selected community pharmacies and lets patients collect medications free of charge—placing community pharmacists in an ideal position to spot potentially inappropriate medications and raise deprescribing conversations. The expansion of pharmacy colleges from three in 2008 to roughly 28 may help build the workforce, though geriatric training capacity will need deliberate investment.

Researchers behind the review lay out a concrete roadmap: the Saudi Geriatric Society should develop a validated Arabic tool and national deprescribing guidelines; pharmacist-led initiatives should be built in collaboration with geriatricians; the Saudi Society of Clinical Pharmacy should embed core deprescribing competencies into PharmD curricula; and multicenter interventional studies must replace the current survey-based literature. The global evidence shows pharmacists can identify inappropriate medications, engage patients and prescribers, and monitor withdrawal—but also that clinical benefits remain uncertain and implementation hinges on authority, workflow, and record access. Saudi Arabia has the demographic momentum, the digital infrastructure, and a young pharmacy profession. What it lacks is the evidence and the rules. The coming decade of aging will test whether it builds both in time.

Subject of Research: Pharmacist-led deprescribing of potentially inappropriate medications in older adults in Saudi Arabia

Article Title: Pharmacist-led deprescribing of potentially inappropriate medications in older adults in Saudi Arabia: a narrative review

Article References: Alamer, K. A., & Alotaibi, F. M. (2026). Pharmacist-led deprescribing of potentially inappropriate medications in older adults in Saudi Arabia: a narrative review. Pharmacia, 73, Article e211525. https://doi.org/10.3897/pharmacia.73.e211525

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e211525

Keywords: deprescribing, polypharmacy, pharmacists, older adults, Saudi Arabia, potentially inappropriate medications, geriatric pharmacotherapy, medication safety, Pharmacist-led, potentially, inappropriate, medications