Saudi Arabia continues to have a relatively young population, but population aging is accelerating. Adults aged 60 years or older accounted for approximately 6% of residents in 2024 (General Authority for Statistics 2024), and United Nations medium-variant projections place this group at approximately 2.8 million by 2035 and 5.7 million by 2050 (United Nations 2024). This change is occurring in a population in which chronic disease is already common. In a nationwide 2022–2023 survey of 2,702 adults aged 60 years or older, 52% reported at least two chronic conditions, most commonly hypertension, hypercholesterolemia, and type 2 diabetes (Bindhim et al. 2025). As multimorbidity increases, care from multiple clinicians may increase medication exposure and contribute to prescribing cascades.

Polypharmacy is commonly defined as the concurrent use of five or more medications, although definitions differ by threshold, duration, clinical setting, and whether appropriateness is considered (Masnoon et al. 2017). In the Saudi National Survey for Elderly Health, 51.5% of 2,946 community-dwelling adults aged 60 years or older used five or more therapeutic classes (Aljawadi et al. 2022). Among older adults, polypharmacy is associated with adverse drug reactions, drug interactions, falls, cognitive and functional impairment, hospitalization, non-adherence, and higher healthcare expenditure. Much of this evidence is observational and partly reflects multimorbidity and inconsistent definitions (Davies et al. 2020). Adverse drug reactions account for an estimated 8.7% of hospital admissions among older adults (Oscanoa et al. 2017). Potentially inappropriate medications are treatments for which likely harm outweighs expected benefit after considering health status, prognosis, treatment goals, and available alternatives (By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel 2023). Medication count alone does not determine appropriateness because a complex regimen may be justified, while a shorter regimen may still include a potentially inappropriate medication.

Deprescribing provides a proactive, supervised process for reducing or stopping medications that no longer fit the patient’s treatment goals or benefit–harm balance. It is better viewed as a continuous part of good prescribing, in which previous decisions are reviewed as health status, priorities, access, and treatment burden change, rather than as withdrawal of care (Reeve et al. 2015; Scott et al. 2015). This approach has received international support through the World Health Organization’s Medication Without Harm challenge and subsequent deprescribing networks (World Health Organization 2017; Mangin et al. 2018).

Pharmacists can support deprescribing through medication reconciliation and medication therapy management (MTM), patient education, communication with prescribers, and follow-up. Community pharmacists may also identify nonprescription medications absent from the clinical record, while in-person and remote home inventories can improve medication ascertainment (Alamer et al. 2024). However, pharmacist-led interventions change medication use more consistently than they change how patients function or feel, and short follow-up remains a common limitation (Chua et al. 2024; Linsky et al. 2025). This review describes current pharmacist-led deprescribing initiatives in Saudi Arabia. It also examines which pharmacist-led models change prescribing, why patient-level benefits remain uncertain, and what implementation would require in Saudi Arabia, where attitudinal studies and one small controlled pilot exist but multicenter randomized evidence remains absent.

Published definitions of deprescribing converge on a planned and supervised process of reducing or stopping a medication to improve outcomes but differ in whether dose reduction and patient goals are explicit (Reeve et al. 2015). Scott et al. translated this concept into five steps: establish the complete medication list and indications; assess overall medication-related harm; compare the benefits and harms of each medication; prioritize withdrawal; and implement the change with follow-up (Scott et al. 2015). The process is individualized and directed by current goals of care, not medication count alone. Deprescribing also introduces risk. Physiological withdrawal, symptom recurrence, disease relapse, and patient anxiety may follow cessation, which makes tapering and active monitoring part of the intervention (Reeve et al. 2018; Hanlon and Gray 2022). Cost, treatment burden, and adherence to the remaining regimen should be considered when a safer alternative is introduced (Linsky et al. 2019). In a Danish nursing-home study, structured symptom assessment was feasible and provided information on possible benefits and harms after deprescribing, but the study did not establish the incidence of adverse drug withdrawal events (Dalin et al. 2022). These tradeoffs should be discussed with the patient before treatment is changed.

Patients with multimorbidity and polypharmacy are candidates when treatment burden, drug–disease interactions, or limited expected benefit make the regimen inconsistent with current goals. Frailty, dementia, limited life expectancy, hospital discharge, transfer to post-acute care, and residence in long-term care provide further reasons to reassess treatment (Kua et al. 2019; Shrestha et al. 2020; Vasilevskis et al. 2023). However, patients with advanced frailty, cognitive impairment, or limited prognosis have the clearest rationale for deprescribing and remain poorly represented in large randomized trials (Shrestha et al. 2020; Ibrahim et al. 2021). Linsky et al. help explain this gap by separating the decision to deprescribe from the process and locating both within patient, prescriber, and system influences (Linsky et al. 2019). Affordability, access, health beliefs, clinical judgment, workflow, and organizational culture can determine whether an otherwise appropriate recommendation is accepted and implemented.

Deprescribing interventions reduces medication counts more consistently than they improve clinical or patient-reported outcomes (Carollo et al. 2024; Chua et al. 2024). In the community-based EMPOWER study, patient-directed education led 27% of long-term benzodiazepine users to discontinue compared with 5% under usual care, and another 11% reduced the dose (Tannenbaum et al. 2014). Hospital-initiated Shed-MEDS continued through post-acute care, where a pharmacist- or nurse practitioner-led intervention produced 14% fewer medications at discharge and 15% fewer at 90 days; adverse drug events did not differ significantly (hazard ratio 0.83, 95% confidence interval 0.52–1.30) (Vasilevskis et al. 2023). Among community-dwelling older adults, Linsky et al. found moderate-certainty evidence for a small reduction in medication or potentially inappropriate medication count (mean difference –0.14, 95% confidence interval –0.27 to –0.01), approximately one fewer medication per seven patients treated (Linsky et al. 2025). The proportion with at least one potentially inappropriate medication was not significantly reduced (odds ratio 0.92, 95% confidence interval 0.74–1.14). Mortality, hospitalization, physical functioning, and quality-of-life findings remain inconsistent because trials are often underpowered and follow-up is short. Observational estimates of adverse drug and withdrawal events also require careful causal methods because the decision to deprescribe is not random (Li et al. 2025).

Economic evaluations show direct medication-cost savings more clearly than long-term health system savings. Avoided admissions and adverse events are often modeled rather than measured, while intervention costs are captured inconsistently (Romano et al. 2022; Hung et al. 2023). Costs can also shift when a potentially inappropriate medication is replaced rather than stopped, so lower medication count and lower expenditure should not be treated as equivalent outcomes.

Several tools are used in clinical practice to identify potentially inappropriate medications. These tools can be broadly classified as explicit or implicit. Explicit tools apply predefined criteria based on medications or clinical conditions. Because they require less clinical judgment, they can be more readily incorporated into electronic health systems. Common examples include the American Geriatrics Society Beers Criteria and the Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to Right Treatment (STOPP/START) criteria (Isop et al. 2025). In contrast, implicit tools require clinicians to evaluate each medication in relation to the individual patient’s clinical conditions, treatment effectiveness, goals, and preferences. The Medication Appropriateness Index is a commonly used implicit tool (Hanlon and Schmader 2013). MTM and the Good Palliative-Geriatric Practice algorithm are broader medication-review approaches rather than explicit screening criteria.

The American Geriatrics Society Beers Criteria® is a well-established explicit tool first developed by Mark Beers and colleagues in 1991. The most recent update was published in 2023 (By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel 2023). The criteria are widely used by physicians and pharmacists to identify potentially inappropriate medications in older adults. They include five categories: medications potentially inappropriate for most older adults; medications potentially inappropriate in specific diseases or syndromes; medications to be used with caution; potentially important drug–drug interactions; and medications that should be avoided or require dosage adjustment according to kidney function. Although the Beers Criteria have been used in several Saudi studies, their evidence base was not developed specifically for Saudi or Middle Eastern populations. Local application therefore requires consideration of population characteristics, prescribing practices, and available alternatives. The criteria also reflect medications available in the United States and may not fully correspond to medications registered by the Saudi Food and Drug Authority. A validated Arabic adaptation tailored to the Saudi context and its clinical and formulary considerations has not been established. The STOPP/START criteria are also widely used to identify potentially inappropriate prescribing in older adults (O’Mahony et al. 2023). The original criteria were published in 2008, followed by version 2 in 2015 and version 3 in 2023. The Screening Tool of Older Persons’ Prescriptions identifies potentially inappropriate prescriptions, whereas the Screening Tool to Alert to Right Treatment identifies potential prescribing omissions among older adults. Both components organize the criteria by physiological system. Unlike the Beers Criteria, STOPP/START was developed through a European expert consensus process (O’Mahony et al. 2023). A validated Arabic version suitable for routine use in Saudi Arabia has not been established. The criteria were developed mainly from European evidence and clinical practice. Their use in Saudi Arabia therefore requires consideration of local formularies, prescribing patterns, and clinical context.

The Medication Appropriateness Index (MAI) is an implicit tool developed to assess prescribing appropriateness in older adults (Hanlon and Schmader 2013). It was developed in the early 1990s to support systematic evaluation of medication regimens in a population at increased risk of adverse drug reactions. The MAI applies 10 criteria to each medication and requires clinical judgment regarding indication, effectiveness, dosage, correct directions, practical directions, drug–drug interactions, drug–disease interactions, duplication, duration, and cost. Each criterion is rated as appropriate, marginally appropriate, or inappropriate. The MAI has established reliability, but its application is time-intensive and requires detailed clinical information, including diagnoses, laboratory results, and medication history. These requirements may limit its routine use in community pharmacies and busy ambulatory clinics. A validated Arabic version tailored to Saudi Arabia or other Gulf Cooperation Council countries has not been established, and regional use remains limited. These tools can identify medications that warrant review, but they do not by themselves constitute a deprescribing plan. A deprescribing plan must also consider age, frailty, comorbidities, treatment goals, patient preferences, economic circumstances, and institutional factors. Explicit tools apply standardized criteria and may not capture important differences between a relatively healthy 65-year-old and a frail 88-year-old. Their recommendations must therefore be interpreted within the patient’s clinical context and goals of care. Explicit tools identify potentially inappropriate medications but generally provide limited guidance on tapering, monitoring, or managing withdrawal. Different tools may classify the same medication differently because they use different criteria and were developed for different settings. Their findings should support, rather than replace, individualized clinical judgment and shared decision-making.

Pharmacists assess the complete regimen across diseases and care settings rather than focusing on one condition. Repeated community-pharmacy contact supports discussion of prescription and nonprescription medications, while medication reconciliation at admission and discharge identifies discrepancies that can otherwise persist across transitions (Mekonnen et al. 2016; Bužančić et al. 2022). Home medication inventories have also shown that older adults possess nonprescription products that may not appear in the electronic record and that ascertainment is feasible in person or remotely (Alamer et al. 2024). The pharmacist therefore connects complete medication ascertainment and whole-regimen assessment with an implementation pathway shared with the prescriber.

The usual model begins with a Best Possible Medication History obtained from the patient or caregiver and checked against available records, followed by a structured review of indication, benefit–harm balance, duplication, treatment burden, alternatives, and patient goals (Gleason et al. 2004; Scott et al. 2015). A major implementation gap often occurs after the review. Among non-hospitalized older adults, acceptance of pharmacist recommendations ranged from 42% to 93%, but implementation ranged from 27% to 88%; integrated general practices reported the highest pooled acceptance at 79% (95% confidence interval 52–97%) (Ramsey et al. 2025). A recommendation without a named prescriber, a route to modify the prescription, and clear responsibility for monitoring are unlikely to be implemented (Wang et al. 2024). Shed-MEDS illustrates an intensive pathway in which pharmacist- or nurse practitioner-led review started in hospital, continued through post-acute care, and included implementation (Vasilevskis et al. 2023). After a change, the plan should state whether direct cessation or tapering is required, the monitoring interval, expected withdrawal or recurrent symptoms, and criteria to pause, restart, or substitute treatment. These decisions are medication-specific; deprescribing guidelines and American Geriatrics Society (AGS) guidance on alternatives provide class-based tapering or replacement options (Pottie et al. 2018; American Geriatrics Society Beers Criteria Alternatives Panel and Steinman 2025). Symptom scales may add information that broad quality-of-life measures miss, although evidence is limited to feasibility work (Dalin et al. 2022).

Patient education can influence whether a recommendation is discussed and acted upon. In the D-PRESCRIBE study, 489 older adults from 69 community pharmacies received pharmacist-led education together with a pharmaceutical opinion sent to the prescriber; 43% discontinued the targeted medication compared with 12% under usual care (risk difference 31%, 95% confidence interval 23–38%) (Martin et al. 2018). Moreover, the EMPOWER study showed that a patient-directed brochure can prompt discontinuation without pharmacist-led clinical review (Tannenbaum et al. 2014). Pharmacists can translate this patient engagement into treatment change by explaining why a medication is being reconsidered, eliciting concerns, and agreeing on monitoring. Willingness cannot be assumed: Shed-MEDS participants or surrogates accepted 63% of recommendations (Kim et al. 2023). For example, pharmacist-based primary care models have reduced anticholinergic exposure, but observational evidence has not established cognitive or functional benefit (Campbell et al. 2022). Published protocols address this gap: Brain-SAFE tests consumer-facing technology, whereas R2D2 tests pharmacist-led deprescribing with 24-month follow-up; neither protocol provides efficacy results (Abebe et al. 2021; Campbell et al. 2024). Behavioral strategies may support action, but the NUDGE-EHR adaptive trial found that most alert features did not improve deprescribing; encounter timing and precommitment were more promising in secondary analyses (Lauffenburger et al. 2025). This favors an iterative approach in which prompts are tested and adjusted to the clinical workflow rather than implemented as a fixed solution.

Globally, pharmacist authority ranges from advisory review to collaborative and independent prescribing. In the United States, collaborative practice agreements can delegate defined medication-management functions within state law and organizational policy (Centers for Disease Control and Prevention 2017). In England, clinical pharmacists are embedded in general practice, and qualified independent prescribers can alter treatment without separate authorization for each change (NHS England n.d.a; NHS England n.d.b). In Canada, the RxACTION study showed that community pharmacist prescribing with follow-up improved blood pressure control, although the trial addressed hypertension rather than deprescribing (Tsuyuki et al. 2015). Australian models remain dependent on legislation, professional endorsement, competence, governance, and access to clinical information (Pharmacy Board of Australia 2023). These differences determine whether a pharmacist can identify a candidate, recommend a change, or prescribe and monitor it. Training, role clarity, record access, and physician collaboration remain necessary under each model (Jebara et al. 2018), and international findings cannot be transferred without examining the local scope of practice.

Studies in Saudi Arabia and other settings have identified barriers and facilitators to deprescribing. Reported barriers include involvement of multiple prescribers, absence of clear policies and guidelines, limited resources, competing patient priorities, and limited clinician knowledge (Alrasheed et al. 2018; Nadarajan et al. 2018; Achterhof et al. 2020; Davila et al. 2022). System-level barriers include limited consultation time, complex care pathways, unclear medication ownership or authority to deprescribe, incomplete health records, particularly in long-term care facilities, and poor continuity of care. Factors that may prompt or facilitate deprescribing include adverse drug reactions, transitions between clinicians or care settings, admission to a nursing home or long-term care facility, informed patients and caregivers, clinician and pharmacist education, and sufficient time to conduct MTM (Reeve et al. 2016; D’Avanzo et al. 2020; Zimmerman et al. 2020).

Saudi Arabia has a relatively young population, but older adults are projected to comprise approximately 14% of the population by 2050 (United Nations 2024). This demographic transition will require close monitoring of healthcare capacity and a coordinated national response. Relevant priorities include healthcare delivery, workforce preparation, and infrastructure (Alamer 2026). Saudi studies have reported polypharmacy prevalence ranging from 34% to 76% (Aljohani 2025; Alharby et al. 2026). Potentially inappropriate medications are also common, with prevalence estimates ranging from 43% to 80% (Al-Omar et al. 2013; Jastaniah et al. 2018; Alotaibi 2023). This variability likely reflects differences in study design, definitions, clinical settings, and regional populations. Most Saudi studies of potentially inappropriate medications in older adults have applied the Beers Criteria. Many of these studies have limited sample sizes and generalizability (Alotaibi 2023). Reported correlates of polypharmacy include multimorbidity and involvement of multiple prescribers (Aljohani 2025; Alharby et al. 2026). These factors, together with limited deprescribing guidance, may make medication addition more common than medication withdrawal.

Saudi studies have identified limited consultation time, heavy clinical workload, concern about withdrawal symptoms, absence of a national framework, limited local evidence, and lack of clear institutional guidance as barriers to deprescribing (Alamer et al. 2025). From the patient perspective, international evidence suggests that many patients are willing to consider deprescribing when it is recommended by a trusted healthcare professional (Kim et al. 2023; Linsky et al. 2025). Saudi pharmacists have also reported adequate knowledge and positive attitudes while identifying limited training, time, and authority as barriers (Alamer et al. 2025). Local intervention evidence in Saudi Arabia remains limited. Only one small ambulatory-care pilot has been reported, while randomized and experimental studies remain scarce (Bawazeer et al. 2022). No Saudi study has evaluated both the economic and patient-reported outcomes of deprescribing. Long-term effectiveness and implementation have also not been evaluated. Although the available evidence suggests that clinicians and patients may be willing to consider deprescribing, this does not confirm its feasibility or effectiveness in routine practice. Despite these barriers, several initiatives under Saudi Vision 2030 may support deprescribing and improve the medication experience of older adults. One of these initiatives is NPHIES, which was launched in 2022 by the Council of Health Insurance (CHI). NPHIES aims to unify health records across private and government sectors in Saudi Arabia (Almazrou 2024). A unified health record may reduce fragmentation between healthcare institutions and allow healthcare providers to review the patient’s complete medication list. It may also support information exchange, medication optimization, and identification of potentially inappropriate medications (PIMs) through standardized medication coding. Wasfaty is another important initiative. This e-prescription platform was introduced by the Ministry of Health in 2019 to improve medication availability and healthcare delivery (Alkathiri et al. 2025). Wasfaty connects primary care centers and hospitals with selected community pharmacies and allows patients to collect medications free of charge. This places community pharmacists in a suitable position to identify PIMs and discuss deprescribing opportunities. However, implementation will require more pharmacists with training in geriatrics. The expansion of pharmacy and medical colleges from three in 2008 to approximately 28 may help increase the healthcare workforce (Alotaibi 2025). The Health Specialties Authority should also establish and accredit more geriatric training sites to increase the number of specialized pharmacists.

Deprescribing requires multidisciplinary work, supportive policies, and trained healthcare providers. Several practical steps are needed. First, the Saudi Geriatric Society (SGS) should develop a validated tool to identify PIMs and clear guidelines for deprescribing. Second, pharmacist-led deprescribing initiatives should be developed in collaboration with geriatricians. Third, the Saudi Society of Clinical Pharmacy (SSCP) and experts in this field should develop core deprescribing competencies for PharmD curricula in Saudi colleges of pharmacy. Finally, interventional studies are needed to complement the existing attitudinal survey-based research.

In conclusion, deprescribing research in Saudi Arabia remains limited. Most published studies have focused on healthcare providers’ knowledge, attitudes, and readiness, while few interventions have been tested in practice. Saudi Arabia also lacks a validated Arabic tool to identify PIMs and clear policies and guidelines to support deprescribing in routine care. However, Saudi Vision 2030 initiatives, including Wasfaty, NPHIES, and the digital health transformation, may provide opportunities to improve medication use and deprescribing among older adults.