Deprescribing after DBS in Dystonia: Promise, Pitfalls, and a Path Forward

Abstract

This timely study adds useful real-world evidence that deep brain stimulation (DBS) may simplify dystonia care by lowering anticholinergic (AchD) exposure and reducing botulinum neurotoxin (BoNT) use across pediatric and adult cohorts.1 While the findings are promising, several limitations and future directions merit discussion. First, the inclusion criterion of “completed DBS and ≥12-month follow-up” risks selection/survivorship bias. Patients with poor response, early complications, or disengagement from care are less likely to meet this threshold and thus are under-represented.2 The resulting analytic sample enriches for adherent “survivors,” which can systematically overestimate the proportion who successfully reduce or discontinue AchD/BoNT relative to the full surgical population. Second, the study was conducted in high-level referral centers where patients typically have higher socioeconomic resources and better access to multidisciplinary follow-up3. Such settings facilitate structured tapering, remote troubleshooting, and rapid re-optimization—all factors that can inflate observed effectiveness and “deprescribing” success. External validity is therefore limited: outcomes may differ in community hospitals or resource-constrained systems. Validation across diverse care levels and payer environments would strengthen policy relevance. Third, the paper establishes that medication and injection needs decline on average but stops short of actionable guidance. Clinicians still need to know “who” can taper, “when” to start, “what” to taper first, and “how fast” to proceed while minimizing rebound risk. Without stratified, quantitative pathways—by phenotype (eg, cervical vs generalized), age group, etiology, baseline burden, and DBS parameters—the value for day-to-day decision-making is modest.4 Data Science/AI. Using routinely collected variables—history, severity scales, adverse effects, AchD/BoNT trajectories, and DBS settings—predictive models could generate patient-specific recommendations (“which class to taper first, by how much, and when to attempt discontinuation”) with uncertainty estimates. Short-term relapse-risk forecasts (4–12 weeks) would support stepwise, reversible tapering and earlier rescue when needed. Implementation Science/Public Health. Embedding these recommendations into standardized care pathways—clear follow-up intervals, remote assessments, and shared tasking between physicians, pharmacists, and nurses—allows pragmatic testing across tertiary, regional, and community sites. Using RE-AIM/CFIR frameworks and stepped-wedge or cluster designs, programs could evaluate effectiveness, cost, and equity, iteratively refining protocols before scale-up. Recommendations: Future work should (i) adopt prospective designs with intention-to-treat cohorts and transparent handling of informative loss to follow-up; (ii) report stratified taper algorithms with prespecified thresholds and rollback criteria; (iii) incorporate patient-reported outcomes, cognitive measures, safety endpoints, and health-economic analyses; and (iv) test pathway fidelity and outcomes across heterogeneous systems. In sum, the authors convincingly highlight a promising benefit of DBS—treatment simplification. Advancing from association to actionable guidance will require prospective, protocolized, and equity-minded research, coupled with translational frameworks that make deprescribing safe, scalable, and fair. We applaud this important first step and encourage the next phase toward implementable, patient-centered care. (1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the first draft, B. Review and Critique. Z.Z.: 1A, 1B, 2A, 3A S.Z.: 1A, 1B, 2A, 3A H.C.: 1C, 2A, 2B, 2C, 3B Ethical Compliance Statement: The author confirms that the approval of an institutional review board was not required for this work. The author confirms that informed patient consent was not required for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Funding Sources and Conflict of Interest: Funding for this work was provided by National Natural Science Foundation of China (No. 82360498); Gansu Joint Scientific Research Fund Major Project (No.23JRRA1537); the 2025 Central-Guided Local Science and Technology Development Found (No. 25ZYJA003); Gansu Provincial Health Industry Science and Technology Innovation Major Project (No. GSWSZD2024-01); Gansu Province Key Talent Project (No.2025RCXM067); Gansu Province Health Industry Research Project（GSWSKY2024-72); In-House Scientific Research Project of Gansu Provincial Hospita（24GSSYC-7); and Natural Science Foundation of Gansu Province (23JRRA1304). The authors declare no conflicts of interest that pertain to this work. Financial Disclosures for the Previous 12 Months: The authors declare that there are no additional disclosures to report. The data that support the findings of this study are available from the corresponding author upon reasonable request.