Polypharmacy Guidance, Realistic Prescribing

This guidance from the Scottish Government and NHS Scotland aims to help prevent inappropriate polypharmacy, particularly in patients with multimorbidities or frailty. It includes ‘7-Steps’ to provide a clear structure for both the initiation of new and review of existing treatments.

Adverse drug events are the cause of 8.6 million unplanned hospital admissions in Europe every year, and half of these events are preventable. Around 70% of these admissions are in patients over the age of 65 who are on five or more medicines.

Most medical research, most guidelines, and many aspects of the GP contract focus on single disease states, whereas in reality most patients have multi-morbidities and need multiple treatments. Unfortunately, the resulting polypharmacy can result in the risks of drug treatment beginning to outweigh the benefits for the individual.

It is said that caring for patients with multi-morbidity and polypharmacy is one of the biggest challenges, not just for nurses managing long-term conditions in UK general practice, but nationally and internationally.

All healthcare professionals have a role to play in managing polypharmacy issues, and the combined knowledge and experience of physician, pharmacist, nurse and patient are required to ensure treatment is optimised to achieve the intended, and patient’s preferred, outcomes. While a pharmacist may be the ideal person to conduct a medicines review, the general practice nurse is well-placed to consider the patient holistically.

Polypharmacy simply means ‘many medications’, and in many cases is often beneficial. For example, secondary prevention of myocardial infarction may require at least four different drugs – antiplatelets, statin, ACE inhibitor, beta blocker.

WHAT IS APPROPRIATE POLYPHARMACY?

Appropriate polypharmacy is when all drugs prescribed for the individual patient are:

• Prescribed for the purpose of achieving specific therapeutic objectives, agreed with that patient
• When those objectives are being achieved or will be achieved in the future
• Drug therapy has been optimised to minimise the risk of adverse drug reactions (ADRs)
• The patient is motivated and able to take all medicines as intended.

WHAT IS INAPPROPRIATE POLYPHARMACY?

Inappropriate polypharmacy occurs when:

• Patients are continuing to take medicines that are no longer needed, for which there is no evidence-based indication, the indication no longer exists, or at an unnecessarily high dose
• One or more medicines fail to delivering the intended therapeutic objectives,
• One or more drugs is causing unacceptable ADRS, or putting the patient at risk of such events
• The patient is not willing or able to take one or more medicines as intended.

Consider polypharmacy at any point of contact involving medication but particularly at the point of prescribing and medication reviews.

Patients at the highest risk of inappropriate polypharmacy are those with the greatest frailty, taking the most medications, or taking high risk medicines. These include:

• Positive inotropic medicines, e.g. diclofenac, digoxin
• Diuretics, e.g. benfroflumethiazide, spironolactone, furosemide
• Drugs for hypertension/heart failure, e.g. ramipril, elanapril, losartan
• Anticoagulants and protamine, e.g. warfarin, rivaroxaban, edoxaban, apixaban, dabigatran
• Antiplatelets, e.g. clopidogrel, dipyridamole
• Hypnotics and anxiolytics, e.g. benzodiazepines, Z-drugs
• Antipsychotic/antimanic drugs, e.g. amisupride, risperidone
• Antidepressants, e.g. amitriptyline, fluoxetine, paroxetine
• Opioid analgesics, e,g. tramadol, co-codamol, morphine, fentanyl
• Drugs for rheumatic diseases, e.g. NSAIDs, corticosteroids, methotrexate

These drugs/classes have been found to be associated with a significant burden of ADRs on hospital admission. While they have proven benefit for patients, measures should be taken to minimise the occurrence of ADRs.

7-STEP PLAN FOR MEDICATION REVIEW

Step 1: Aim – What matters to the patient

• Identify aims and objectives of drug therapy and ask the patient ‘What matters to you?’
• Explain any key information such as laboratory markers
• Establish treatment objectives with the patient through shared decision making

Step 2: Need – Identify essential drug therapy

• Separate the list of medicines which the patient is taking
• Ensure the patients understands the importance of essential drug therapy
• Include all medication, whether herbal, prescribed or traditiona;

Step 3: Need – Does the patient take unnecessary drug therapy?

• For the remaining drugs, verify that each has a function in achieving the therapeutic goals or outcomes that matter most to the patient
• Review preventative treatment to ensure that the patient is able to continue taking medicine for the required time to gain benefit
• Can lifestyle changes replace any unnecessary drug therapy?

Step 4: Effectiveness – Are therapeutic objectives being achieved?

• Check treatment choice is the most effective to achieve intended outcomes
• If outcomes are not being achieved, consider investigating non-adherence or dose titration. (50% of patients taking four or more medicines don’t take them as prescribed).

Step 5: Safety – Is the patient at risk of ADRs or suffering actual ADRs?

• The presence of ADRs can sometimes be identified from laboratory test results, e.g. hypokalaemia from diuretic use
• The patient may report symptoms of ADRs, including drug-drug and drug-disease interactions, and also the patient’s ability to self-medicate
• Ask the patient specific questions, e.g. about the presence of anticholinergic symptoms, dizziness or drowsiness. If the patient is experiencing ADRs, use Yellow Card Reporting [https://yellowcard.mhra.gov.uk]

Step 6: Efficiency – Is drug therapy cost-effective?

• Explore opportunities for cost minimisation but only change drugs for cost reasons if effectiveness, safety or adherence would not be compromised
• Ensure prescribing is in line with current formulary recommendations

Step 7: Patient centred – Is the patient willing and able to take drug therapy as intended?

• Does the patient understand the outcome of the review?
• Ensure drug therapy is tailored to patient preferences
• Agree and communicate plan with patient and/or welfare proxy
• Even if an adult lacks capacity, the Incapacity Act still requires that the adult’s views are sought

CASE FINDING

Emerging evidence demonstrates the importance of targeting patients with high-risk prescribing, Holistic, face-to-face review of these patients reduces risk for the individuals and also demonstrated a reduction in hospital admissions.

Priority for review should be patients who are:

• Aged 50 years and older, and resident in a care home regardless of how many medicines are prescribed
• Prescribed 10 or more medicines
• On high-risk medication
• Approaching the end of their life: adults of any age, approaching end of life due to any cause, are likely to have different medication needs, and risk versus benefit discussions will often differ from healthy adults with longer expected life spans.

If it is not realistic to review all of these patient groups immediately, the criteria can be further stratified by

• Age – e.g. 75 years and older, then 65 years and so on, as resources allow
• Frailty – using the frailty score used in your practice
• Dominant condition – e.g. dementia. Some conditions dominate patient care as they impact and inform decisions for all other conditions.

POTENTIALLY UNNECESSARY DRUG THERAPY

Check for expired indication – does the patient still need to be on this medication?

• PPI/H2 blocker
• Laxatives
• Antispasmodics
• Oral steroid
• Hypnotics/anxiolytics
• H1 blockers
• Metoclopromaide
• Antibacterials
• Antifungals
• Sodium/potassium supplements
• Iron supplements
• Vitamin supplements
• Calcium/Vitamin D
• Sip feeds
• NSAIDs

DRUGS POORLY TOLERATED IN FRAIL ADULTS

• Antipsychotics
• NSAIDs
• Digoxin (doses ≥ 250mcg)
• Benzodiazepines
• Anticholinergics (including trycyclic antidepressants [TCAs]) – see anticholinergic effects, below
• Combination analgesics

HIGH RISK CLINICAL SCENARIOS

A number of medications are associated with an increased risk of ADRs, notably dehydration, when the patient has sickness and/or diarrhoea, or fever. These include

• ACE inhibitors
• ARBs
• Diuretics
• Drugs for glycaemic control
• NSAIDs

Other drugs pose increased risk of ADRs in combination with other drugs/conditions – see Table 1.

• NSAID + age>75 (without PPI)
• NSAID + HO peptic ulcer
• NSAID + antithrombotic
• NSAID + CHF
• Glitazone + CHF
• Warfarin + macrolide/quinolone
• ≥2 anticholinergics

Anticholinergic effects

Anticholinergics commonly cause symptoms such as dry mouth, constipation and urinary retention, but may also be associated with impaired cognition, physical decline, falls, cardiovascular events and mortality. Anticholinergic effects are dose-dependent, but may vary between individual patients. The anticholinergic effect of multiple drugs is accumulative. Where possible and appropriate, consider an alternative (bearing in mind that some alternatives may have other concerns) or reducing the dose.

INTENSIFICATION OF EXISTING DRUG THERAPY

Consider intensifying existing drug therapy when therapeutic objectives are not met, in:

• Constipation
• BP control
• HbA1c control
• INR control
• Heart rate control (rate limiting drugs)
• Respiratory conditions
• Pain control

COST EFFECTIVENESS

Check for:

• Costly formulations (e.g. dispersible)
• Costly unlicensed ‘specials’
• Branded products
• More than 1 strength or formulation of same drug
• Unsynchronised dispensing intervals (28 or 56 day supplies)

ADHERENCE

Check self-administration (cognitive)

• Warfarin/DOACs
• Anticipatory care meds (e.g. in COPD)
• Analgesics
• Methotrexate
• Tablet burden

Check self-administration (technical)

• Inhalers
• Eye drops
• Any other devices
• Bisphosphonates

The guidance is intended to be a practical tool to help prescribers decide when it is appropriate to initiate or continue long-term medicines. In some circumstances it may be appropriate to discontinue treatment. It includes a useful guide to the clinical effectiveness of commonly prescribed drugs, based on numbers needed to treat (NNT) – see page 51 of the full guideline.

For further reading on deprescribing, refer to Chapter 3 of the full guideline – Hot topics: Further reading and deprescribing (Page 35) which includes sections on

• Anticholinergics
• Medication and falls risk in the older person
• Stopping antipsychotics in patients with dementia
• Stopping benzodiazepines and z- drugs
• Management of constipation
• Management of glycaemic control
• Management of chronic pain, and
• Medication in the frailest adults

Reference

Polypharmacy Guidance, Realistic Prescribing 2018 https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf