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June 2019

Multimorbidity and prescribing


About one-in-five patients with more than one medical condition are prescribed 4-9 drugs and 1% are prescribed 10 or more, putting them at risk of adverse effects and drug interactions, so additional care must be taken when prescribing for patients with multimorbidity


This is the second article describing the problems associated with multimorbidity. The previous article outlined the definition, prevalence and outline management of multimorbidity. The focus of this article is advice for practice nurses to assist with rational and appropriate prescribing for people with multimorbidity.

To recap, multimorbidity is defined as a person having two or more long-term health conditions.1 These might include:

  • Physical or mental health conditions, such as diabetes or schizophrenia
  • Ongoing conditions, such as a learning disability
  • Symptom complexes, such as frailty or chronic pain
  • Sensory impairment, such as sight or hearing loss
  • Alcohol or substance misuse.

Over a quarter of the UK population can be described as suffering from multimorbidities.


POLYPHARMACY AND MULTIMORBIDITY

Approximately 20% of people with two medical conditions are prescribed 4–9 drugs and 1% are prescribed 10 or more.2 The inherent risks of polypharmacy are adverse drug effects, drug interactions, potentially inappropriate prescribing, and reduced drug adherence.3

The greater the number of chronic conditions, the greater the likelihood of patient-reported safety incidents. Evidence from populations aged 65 years or over also suggests that treatment by multiple prescribers is an independent predictor of reports of adverse drug events.3

The broad principles of management include

  • Using shared decision-making principles.
  • Maximising benefit from existing treatments, including stopping treatments with limited benefit or have a high treatment burden or have a high risk of adverse events.
  • Coordinating appointment to minimise impact.
  • Identifying simple non-pharmacological treatments.
  • Using a structured prescribing tool (for example, the STOPP/START tool in older people).

In this article we are going to focus on the prescribing elements of managing a person with multimorbidities.


MANAGEMENT IN DETAIL

The specifics of rationalising prescribing will clearly be different for each individual, their circumstances, preferences and risks. However, the evidence base points to particular areas which are worth considering for every individual who has multimorbidity and problems with polypharmacy.

There have been several attempts to provide prescribers with an objective framework to support safe and effective prescribing. The most widely used and locally adapted in the UK are the STOPP/START criteria.

Version 2 of the STOPP/START tool provides some overarching principles. For example, it advises that the following prescriptions are potentially inappropriate to use in patients aged 65 years and older.6

1. Any drug prescribed without an evidence-based clinical indication.

2. Any drug prescribed beyond the recommended duration, where treatment duration is well defined.

3. Any duplicate drug class prescription for example, two concurrent NSAIDs, SSRIs, loop diuretics, ACE inhibitors, anticoagulants.


The Screening Tool of Older Persons’ Prescriptions (STOPP) criteria focus on the concept of ‘deprescribing’, i.e., stopping or reducing the dose or frequency of medications which are of limited benefit or which may increase risk. (Box 1)

The Screening Tool to Alert to Right Treatment (START) element focusses on medications that it may be beneficial to commence in order to improve care or decrease risk.

Box 2 gives some examples to help in framing our discussion of the practicalities for patients.

STOPP CRITERIA

Considering the drugs listed in Box 1, clearly changing, revising drug regimens or stopping such medications should be done carefully and with the appropriate consultation with other members of the primary care team and possibly secondary care colleagues. However, the unintended consequences of taking some of these drugs, including acute kidney injury and other side effects may be so deleterious to a person’s health that serious consideration should be given to stopping any and all of these medications.

High dose non-steroidal anti-inflammatory drugs (NSAIDs) in particular have a challenging safety profile in the elderly and should therefore be used at the lowest effective dose for the shortest possible duration.

When prescribing NSAIDs, consider the person's individual risk factors for adverse effects and consider if alternative to an NSAID may be suitable, for example a topical NSAID or paracetamol, or physiotherapy, or referral for consideration of surgery.

Consider also if

  • The person has any contraindications to oral NSAIDs.
  • There are any potentially hazardous drug interactions.
  • The person is already using an NSAID — for example, ibuprofen or aspirin purchased over-the-counter.
  • Gastroprotection is indicated. For example, because the person is:

– At increased risk of gastrointestinal adverse effects (for example, people that require long-term treatment).

– Experiencing dyspepsia from standard NSAIDs.


More frequent review and monitoring for adverse effects is required — for example, for people who are:

  • At risk of multiple adverse effects

(for example, the elderly, people with comorbidities).

  • Taking drugs which may interact with an NSAID.
  • At increased risk of gastrointestinal or cardiovascular or renal adverse effects.

START CRITERIA

Moving to the Start criteria, treatments for heart failure in particular, when titrated to the maximum tolerated level have a proven benefit in terms of improved longevity. These include ACE and cardio-selective beta-blockers. Titration needs to be slow, methodical, reviewed regularly and intensively monitored by an expert health professional with personal knowledge of the patient. This role is ideally suited to the practice nurse prescriber, who also has access to additional primary and secondary care support.

All these interventions at the population health level have a positive impact on morbidity and mortality. They have an unarguable evidence-base but this needs to be taken into the consultation room and thought through appropriately at an individual level. Practice nurses are ideally placed to undertake such cardiovascular reviews with patients and are already performing many of these interventions on a daily basis. Extending this role into other aspects of management is entirely appropriate using their skills and abilities.

These are two STOPP/START system examples to improve appropriateness of prescribing. It is beyond the scope of this article to detail the full range of criteria, but they are available in the supplementary material listed in the reference section below.

These interventions although simple to enact individually, take the expertise of a nurse prescriber, a detailed knowledge of a patient and time to ensure that the changes are appropriate, understood and follow-up in place in order to provide patient benefit. The potential benefits are well-documented and include:8–10

  • Fewer drug interactions
  • Fewer adverse effects
  • Fewer drug-related complications and deaths
  • Fewer unplanned admissions to hospital
  • More appropriate interactions with the right member of the clinical team
  • Greater patient empowerment

CASE STUDY

Desmond is a 75-year-old man who lives alone on the 8th floor of a block of flats, near the town centre. He has a home help who visits twice a week to assist with cleaning. He also has a daughter who visits every week. Desmond suffers from type 2 diabetes, hypertension, peripheral artery disease, venous leg ulcers and glaucoma.

He is taking three antihypertensive medications, metformin, aspirin, a statin, paracetamol and has daily eye drops.

His blood pressure and diabetes are often not well-controlled, and he struggles to get out of his flat as he has intermittent claudication. He has had three admissions to hospital in the past 12 months, one for pneumonia the other two for complications of his diabetes.

He is brought to the surgery for a routine review of his medication. At this visit he is clearly unhappy. He tells you that he has been more tired and is sleeping for prolonged periods of the day. His appetite is poor, and he feels cold, despite the recent spell of warm weather. He tells you that his legs have been more painful recently. He had been seen by an out-of-hours doctor recently and given some new tablets, which has not brought with him today.

His blood pressure is 148/86mmHg, pulse 82/minute regular, random blood glucose 7.2mmol/l (after lunch). His urine shows ++ protein, his pulses are not palpable below the knee. An assessment of his mood does not provide you with conclusive evidence of depression, but you remain concerned.

You decide to take his blood for u&e, HbA1c, FBC, LFTs, and TFTs.

The next day Desmond’s daughter rings to tell you that the medication he had been given by the out-of-hours doctor was naproxen 250mg. Desmond had been taking 500mg twice daily for the past 10 days.

A few minutes later the laboratory ring with his blood results, which demonstrate AKI stage 1, as his creatinine has risen by 28micromol/l, since his last test 3 months earlier.

You phone Desmond and advise him to stop the new naproxen tablets, as you suspect that these have caused the AKI, fatigue, poor appetite and other symptoms. You gain his consent to ask his daughter to check that he dispose of the naproxen and does not inadvertently take them as part of his regular medication.

You ask your district nurse colleague to review Desmond in 3 days and take another blood sample to check his creatinine level. She tells you that he seemed a little brighter, that he felt less tired and that his appetite had improved a little. The lab phone the following day to advise that his creatinine is now only 12micromol/l higher than the level three months previously.

You ring Desmond to check on his condition. He says that he is on the mend but that his leg pain is still problematic, mainly when he is walking. You advise that he needs to have another assessment of his arteries and arrange a doppler ankle brachial pressure index measurement.

This case study highlights the potential challenging issue of multiple prescribers in different settings changing and adding new medications, particularly for elderly patients with multimorbidity. It also highlights the pivotal role of the practice nurse and their ability to liaise with the wider multidisciplinary team in order to positively influence the course of the patient journey at a time of clinical vulnerability.

CONCLUSION

Multimorbidity is a problem which brings the attendant problem of polypharmacy. People who have two or more chronic conditions and multiple dosing regimens of many different drugs are at high risk of adverse drug reactions, complex drug interactions and unplanned admissions to hospitals.

Managing the competing needs of their individual conditions into a considered single prescribing view is challenging and may change over time.

The complexity of their care should not be underestimated and needs time to arrive at a treatment plan which is both subtly personal and evidence based.

Frameworks such as the STOPP/START criteria provide us with an outline of where to begin when faced with a person with multimorbidities, but we must bring our expertise and judgement to bear when considering the patient in our consultation room.

In doing so, we can hope to provide a management plan which covers reducing the prescribing of unnecessary and risky drugs and instead introducing medication which can provide more comfortable and fuller lives to our patients.

Practice nurses can therefore provide a way for patients and their carers to navigate through this complexity in order to arrive at a plan for best practice prescribing at an individual level.

REFERENCES

1. NICE Clinical Knowledge Summaries Multimorbidity https://cks.nice.org.uk/multimorbidity

2. Payne RA, Avery AJ, Duerden M, et al (2014) Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol 2014;70(5):575-581 https://link.springer.com/article/10.1007%2Fs00228-013-1639-9

3. Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: making it safe and sound, 2013. The King's Fund. https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation

4. Nursing and Midwifery Council. Pre-2019 Standards of proficiency for nurse and midwife prescribers https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-prescribers/standards-of-proficiency-for-nurse-and-midwife-prescribers/

5. Royal Pharmaceutical Society. A Competency Framework for all Prescribers 2016 https://www.rpharms.com/Portals/

0/RPS%20document%20library/Open%20access/Professional%20standards/Prescribing%20competency%20framework/prescribing-competency-framework.pdf?ver=2019-02-13-163215-030

6. O’Mahony D, O’Sullivan D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing 2015; 44(2): 213–218, https://doi.org/10.1093/ageing/afu145 https://academic.oup.com/ageing/article/44/2/213/2812233

7. Gallagher P, Ryan C, et al. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Therap 2008;46(2):72-83 https://europepmc.org/abstract/med/18218287

8. Lavan A, Gallagher PF, O’Mahoney D. Methods to reduce prescribing errors in elderly patients with multimorbidity. Clin Interv Aging 2016;11: 857-66

9. doi:10.2147/CIA.S80280 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922820/

10. Rodríguez-Pérez A, Alfaro-Lara ER, Albinana-Perez S, et al. Novel tool for deprescribing in chronic patients with multimorbidity: List of Evidence-Based Deprescribing for Chronic Patients criteria. Geriatr Gerontol Int 2017: 17: 2200-2207. doi:10.1111/ggi.13062 https://onlinelibrary.wiley.com/doi/full/10.1111/ggi.13062

11. Roughead EE, Vitry AI, et al. Multimorbidity, care complexity and prescribing for the elderly. Aging Health 2011;7(5): https://doi.org/10.2217/ahe.11.64

Dr Gerry Morrow
MB ChB, MRCGP, Dip CBT
Medical Director and Editor, Clarity Informatics Limited









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