POLYPHARMACYAND MEDICINES OPTIMISATIONProfessor Tony Avery, University of Nottingham, in collaboration withDr Martin DuerdenDr Rupert Payne

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“We dislike polypharmacy as much as it is possible, and we would never exhibit a remedy of any kind unless we had a scientific reason for so doing and unless we were prepared to defend our method of treatment.....”

Newnham W. Remarks on the present aspect of medicine. Prov Med Surg J 1848;p281-285Published 31st May 1848. (The Provincial Medical and Surgical Journal was the forerunner to the British Medical Journal)

Scope of presentation• Defining and measuring polypharmacy, and the

concept of deprescribing• Evidence-based polypharmacy and how to evaluate

evidence to judge whether medicines continue to provide net benefit

• The key issues in optimising prescribing in older people

• Key recommendations for service redesign and research needed to improve the management of patients require medicines for multiple conditions

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Issues with polypharmacy• Polypharmacy is an expression that has been used for

many years in medicine; it is generally understood as referring to the concurrent use of multiple medication items in one individual.

• In the past polypharmacy has been frowned upon and considered something to be avoided. It is now accepted that in many circumstances polypharmacy can be therapeutically beneficial.

• Polypharmacy may be harmful as it will increase the risk of drug interactions and adverse drug reactions, together with impairing medication adherence and quality-of-life as regimens may be too complex or unacceptable to patients.

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Definitions• Appropriate polypharmacy is prescribing for an

individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and the medicines are prescribed according to best evidence. The overall intent for the combination of medicines prescribed should be to maintain good quality of life, improve longevity, and minimise harm from drugs.

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Definitions• Problematic polypharmacy is prescribing of multiple

medications inappropriately, or where the intended benefit of the medication is not realised. The reasons for this may be that the treatments are not evidence-based, or the risk of harm from treatments is likely to outweigh benefit, or where one or more of the following apply:

• The drug combination is hazardous because of interactions• The overall demands of medicine taking, or ‘pill burden’ is unacceptable to the

patient• The demands of medicine taking means that it is not possible to achieve

clinically useful adherence (reducing the ‘pill taking burden’ to the most essential medicines is likely to be more beneficial)

• Medicines are being prescribed to treat the side effects of other medicines where alternative solutions are available to reduce the number of medicines prescribed

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Higher risk polypharmacy• All patients with ten or more regular medicines (for example,

those medicines taken every day or every week)• Patients receiving between four and nine regular medicines

who also:• Have at least one prescribing issue meeting criteria for potentially

inappropriate prescribing• Have evidence of being at risk of a well-recognised potential drug-drug

interaction or have a clinical contraindication• Have evidence from clinical records of difficulties with medicine taking,

including problems with adherence• Have no or only one major diagnosis recorded in the clinical record (it

might be expected that large numbers of medicines are unlikely to be justified in patients without multiple clinical conditions)

• Are receiving end of life or palliative care (where this has been explicitly recognised)

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The concept of de-prescribing• The current model of prescribing is based very much

around adding drugs as patients develop more conditions• Given the risks of adverse drug events (especially with the

'therapeutic cascade‘); problems with adherence, and limitations on effectiveness, it is important to consider whether to discontinue some medicines in some patients

• The concept of de-prescribing involves carefully assessing patients’ medicines and (with patient and/or carer consent) withdrawing those that may be harmful or no longer providing benefits

• More on this later…

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Epidemiology of polypharmacy• Demographics• Increases in multimorbidity with age• Comorbidity of common conditions• Prevalence of polypharmacy

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Estimated and projected age structure of the United Kingdom population, mid-2010 and mid-2035http://www.ons.gov.uk/ons/dcp171778_235886.pdf

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Number of Chronic Disorders by Age GroupBarnett K et al. Lancet 2012; 380: 37-43.

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Comorbidity of 10 common conditions among UK primary care patients Guthrie B et al. BMJ 2012;345:e6341

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Prevalence of multiple medicines prescribing in a Scottish primary care population [Payne R, unpublished data]

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Evaluating evidence to judge whether medicines continue to provide net benefit?• Evidence-base for polypharmacy is poor• Nevertheless, prescribers are faced with difficult decisions

when often all we have to go on is evidence-based guidelines for single conditions

• In many cases, however, it does seem appropriate to prescribe multiple medications based on existing 'single condition' evidence provided that:• Benefits are likely to outweigh harms• Patient is willing and able to take the medication• Therapeutic cascade is avoided if at all possible

• There are, however, circumstances where the evidence is not strong enough to justify continued treatment

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Questions to ask when considering stopping medication (WeMeReC 2010)

• Is the drug still needed?• Has the condition changed? • Can the patient continue to benefit?• Has the evidence changed?• Have the guidelines changed?• Is the drug being used to treat an iatrogenic problem?• Are there ethical issues about withholding care?• Would discontinuation cause problems? Some therapies

should not be stopped abruptly following long-term use. • What does the patient/carer think?

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Changing priorities, towards the end of life• As patients with multimorbidity age and become frail, and

preventative treatments become less meaningful, prescribers should consider when it is appropriate to broach the subject of scaling back or stopping treatment

• This then needs a discussion with the patient and caregivers about revision of treatments and limitations on investigations

• Prescribers need to decide in what particular order to taper or eliminate treatments

• NHS Scotland Polypharmacy Guidance, 2012, is helpful here• http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20f

ull%20guidance%20v2.pdf

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NHS Scotland Polypharmacy Guidance• Consider what is the outcome being avoided?• Consider using NNTs per annum to inform decisions of

withdrawal of medication, e.g. NNTs of >50/year for:• Statins post MI (to prevent another major coronary event)• Statins post stroke (to prevent another stroke)• Metformin in overweight diabetic (to prevent MI, diabetes event or

death)• BP <140 systolic in diabetes (to prevent stroke, diabetes event or

death)• Alendronate + calcium/vit D to prevent further fracture

• Consider where NNT>NNH, e.g. Sedative hypnotics in older people with insomnia

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Key issues in optimising prescribing in older people• Thorough medication review is extremely important

• How do we achieve this?• Taking account of drugs that are poorly tolerated

• Antipsychotics, tricyclic antidepressants, benzodiazepines, opioids and anticholinergics

• Taking account of drugs that may still be beneficial• Many cardiovascular medicines

• Monitored dose systems• May help with adherence, may improve some outcomes, but may

also cause problems!• Medicines reconciliation at hospital discharge• Care home settings

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Medication review• Thorough medication review is probably the most

important method for identifying and correcting problems with polypharmacy

• Needs a review of each medicine, and the medication regime as a whole, in terms of:• Right drug?

• Appropriate for the condition with no contraindications or hazardous drug interactions

• Right dose?• Right instructions?• Right monitoring?• Right for the particular patient?

• Can they cope with the medication burden? • Do they want to cope with medication burden?

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Polypharmacy in care home settings• The following may help:

• A lead GP for each home• Pharmacist medication review• One person, (ideally a pharmacist) having overall responsibility for

medicines use in the care home• Regular review of the use and accuracy of medication

administration records (lack of protocols and adequate staff training is an issue)

• Considering the timing of medication administration to ease busy morning drug rounds, which can often be interrupted

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DON’T FORGET WASTE

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Key recommendations for service redesign• Current model is not optimal• Major investment in clinical pharmacy is likely to be

helpful• Detailed medication review for patients at greatest risk, and liaison

with prescribers for medicines optimisation• Care home prescribing particularly important

• PINCER-trial approach to identifying and managing patients with hazardous prescribing and inadequate blood test monitoring

• Having more pharmacists working as independent prescribers in primary care, particularly if this is well-coordinated

• Improving safety systems• Consider the development of specialist GPs, and/or

investment in community geriatricians

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Key recommendations for research• Need much better evidence for the benefits and risks of

polypharmacy in patients with multimorbidity• More trials would be ideal, but consider use of clinical database

studies• More evidence needed on the views of older people

concerning polypharmacy and NNT/NNH• Is prolonging life expectancy the most important issue to all the

people?• More evidence needed on the benefits of different models

of medicines optimisation for older people• Trials needed to assess the benefits and risks of judicious

de-prescribing in older people

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Summary• Polypharmacy is becoming increasingly common,

particularly in older people with multimorbidity• It is important to take account of current evidence when

considering medicines optimisation in older people• Nevertheless, further evidence would be helpful,

particularly in terms of the benefits and risks of de-prescribing

• We know enough already, however, to recognise that clinical pharmacists have an extremely important role in medicines optimisation in older people, and that services need to be redesigned to take account of this

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How can we stop good doctors from making bad mistakes?

Thank you, for listening!