Functional Deprescribing: A Systems-Based Framework for Safe Medication Reduction

Leslie Fuller, ND

Leslie Fuller, ND, Naturopathic Doctor, Professor of Clinical Medicine, University of Western States, Portland, Oregon, USA.

Corresponding author: Leslie Fuller, ND  

E-mail: lfuller@uws.edu

Keywords: Deprescribing, Polypharmacy, Functional Medicine

Introduction

Polypharmacy and long-term medication use are increasingly common in elderly patients, those with chronic disease and multimorbidity, contributing to adverse drug events, reduced physiologic resilience, and diminished quality of life.^1-4 Since 2009, there has been a steady increase in research and literature on the importance and implementation of deprescribing strategies with key at-risk populations. While deprescribing frameworks such as the Beers Criteria, STOPP/START, and drug class-specific algorithms provide essential pharmacologic guidance, they rarely incorporate the functional and lifestyle domains that determine a patient’s ability to tolerate medication withdrawal and maintain stability over time.^5-9 The increasing burden of polypharmacy and medication-related adverse effects highlights an urgent need for safe, structured deprescribing frameworks.^3,4,10

This manuscript proposes a Functional Deprescribing Framework that integrates systems-based physiologic and metabolic support, lifestyle interventions, and functional therapeutics into existing deprescribing models.

Limitations of Current Deprescribing Models

Deprescribing is an emerging and evolving area of clinical research. Current deprescribing models are largely condition or drug-class-specific (antihypertensives, proton pump inhibitors, psychotropics, etc.) and focus primarily on pharmacologic risk-benefit analysis.^6,7,11 Most current publications focused on deprescribing can be categorized into four categories: 1) clinical criteria for identifying ideal deprescribing candidates, 2) educating patients about deprescribing, 3) workflow supports and protocols for medication selection and tapering, and 4) national level initiatives. These existing deprescribing frameworks excel at identifying medications associated with elevated risk or limited benefit.^5,11-13 Despite these strengths, most models offer limited direction on how to support patients through the physiologic and behavioral transitions that accompany medication reduction, and most current deprescribing trials and frameworks rarely include patient-centered goals or lifestyle modification as a core element.

Functional medicine offers complementary tools, including systems-based assessment, root-cause mapping, and biomarker-guided restoration, that may bolster and support physiologic resilience during medication tapering.^14-16 Currently, there is limited published work on integrating functional or lifestyle interventions into deprescribing algorithms. Targeted lifestyle or functional medicine-centered interventions may indirectly support deprescribing by addressing symptoms (e.g., insomnia, anxiety, pain) that often lead to medication use, and by enhancing resilience during medication withdrawal.^10,11,15

Drawing upon current deprescribing literature and functional medicine theory, the proposed Functional Deprescribing Framework emphasizes physiologic preparation, individualized patient’s goal-oriented tapering, stabilization, and monitoring. Reframing deprescribing as a restorative process rather than medication removal alone may enhance safety, personalization, and durability of outcomes while providing a foundation for future clinical research.

Biological Rationale for Functional Support During Deprescribing

Medications exert effects across multiple physiologic systems, including neuroendocrine regulation, metabolic signaling, hepatic biotransformation, renal function, and gastrointestinal function.^11,14 Long-term medication use may alter these systems through mechanisms such as nutrient depletion, autonomic imbalance, microbiome disruption, and altered stress responses. When medications are reduced or withdrawn, these adaptations may become clinically apparent, or “unmasked”. For example, tapering antidepressants or benzodiazepines may reveal underlying autonomic dysregulation or sleep disturbance; withdrawal of proton pump inhibitors may exacerbate hyperacidity; and antihypertensive deprescribing may expose metabolic or inflammatory contributors to blood pressure variability.^17,18 Supporting these systems through nutrition, movement, sleep optimization, and stress regulation is biologically plausible and consistent with a systems-based understanding of health.

The Functional Deprescribing Framework

The proposed Functional Deprescribing Framework is a six-stage patient-centered, adaptive model designed to complement existing deprescribing guidelines by incorporating systems-based physiologic and metabolic support. This framework emphasizes personalization, adaptive pacing, and patient partnership throughout the deprescribing process. Rationale for the individualized steps includes:

• Identify and Assess: Review overall medication burden, flag potentially inappropriate medications (PIMs), and assess key antecedents, triggers, and mediators (ATMs) such as nutrient status, inflammation, sleep, stress load, and metabolic stability.
• Patient Education, Goals, and Readiness: Explore patient beliefs, goals, and readiness for change. Education reframes deprescribing as a therapeutic transition rather than withdrawal of care, sets expectations around temporary symptoms, and supports shared decision-making aligned with quality-of-life priorities.
• Physiologic Preparation: Before tapering, modifiable lifestyle and physiologic factors are optimized to build resilience. This may include nutritional repletion, circadian and sleep support, metabolic and detoxification support, and stress or autonomic regulation.
• Personalized Taper: Medication reduction is personalized, based on pharmacokinetics, patient response, and system stability. Taper pace remains flexible, with anticipatory guidance and targeted supports, layered in as needed.
• Stabilization and Adaptation: As medications are reduced, emerging physiologic imbalances are addressed with lifestyle strategies and functional therapeutics, emphasizing symptom interpretation and support to reduce rebound effects and avoid reflexive re-prescribing.
• Monitoring and Reassessment: Symptoms, function, and quality of life are monitored over time to guide ongoing adjustments in taper pace, supportive strategies, or the need for additional stabilization.

This framework reinforces that deprescribing is an adaptive, restorative process rather than a linear endpoint-focused model, maintaining alignment with established deprescribing principles while including a functional medicine lens.

Barriers, Safety, and Implementation Considerations

Although the proposed Functional Deprescribing Framework has several key differences from current deprescribing models, there are still implementation barriers to identify and address (Figure 1).^4,19-21 Barriers to functional deprescribing include limited clinical time, fragmented or siloed care models, variable clinician training, and patient fear of symptom recurrence.^22-24 Safe medication deprescribing “and the integration of functional medicine approaches to support deprescribing” requires physician education focused on careful monitoring, scope awareness, and collaboration with other potential prescribing clinicians.²⁴

Figure 1. Key Differences and Potential Barriers in a Functional Deprescribing Framework: The Functional Deprescribing Framework complements existing deprescribing guidelines by emphasizing systems-based physiological and metabolic support rather than medication withdrawal alone, though patient and clinician education will need robust and focused support. ^{19,20, 22-24}

Conclusion

Integrating functional medicine principles into deprescribing reframes medication reduction as a restorative process focused on rebuilding patient-centered physiologic self-regulation rather than simply removing medications. This model helps clinicians determine when and how to layer lifestyle and functional strategies to support resilience before, during, and after tapering. It also encourages collaboration between prescribing and non-prescribing clinicians and provides a foundation for future research.

Funding

No funding received for the study

References

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