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Tackling polypharmacy in frail adults

By Clare Morrison

The more medicines a patient takes, the more likely he or she is to suffer side effects. But stopping medicines goes against the grain for many prescribers. To support them make such decisions, NHS Highland has developed guidance on polypharmacy. Its aim is to improve the quality and safety of prescribing in frail adults. In this week’s Journal, some research on the implementation of this guidance is published.

What is the problem?

For some patients, taking a large number of medicines is necessary and appropriate. However, polypharmacy is not always a good thing. Taking more medicines or having more co-morbidities increases the risk of side effects. These side effects may be minor

but some are serious: adverse drug reactions cause around 5 per cent of all hospital admissions and the rate is even higher in frail populations.

Polypharmacy usually creeps in over a number of years as more and more medicines are added to a patient’s repeat prescription list. Patients can end up on the same medicine for 10 or 20 years, or even longer. Although that medicine may have been entirely appropriate when it was started, this may no longer be the case many years later. Changes to patients’ circumstances, such as becoming more frail or developing additional long-term conditions, may have altered its appropriateness.

What is NHS Highland’s solution?

In order to tackle the problems caused by polypharmacy, NHS Highland has developed a policy called “Polypharmacy: guidance for prescribing in frail adults”. The guidance was developed by a team of pharmacists and doctors from both primary and secondary care in NHS Highland, led by consultant physician Martin Wilson.

The guidance is aimed at prescribing for frail adults (frailty is defined as patients with a reduced ability to withstand illness without loss of function) and, in particular, patients taking more than 10 medicines, who have suffered a side effect or who have indications of shortened life expectancy.

Poorly tolerated drugs

The following drugs are poorly tolerated in frail patients

•    Digoxin in doses above 250µg
•    Antipsychotics
•    Tricyclic antidepressants
•    Benzodiazepines (particularly long-term)
•    Anticholingerics
•    Phenothiazines (eg, prochlorperazine)
•    Combination painkillers (eg, co-codamol)

What does the guidance include?

The guidance provides a process for conducting a polypharmacy review, identifies drugs that are tolerated poorly in frail patients, lists high risk drugs and provides a drug effectiveness summary.

The process for conducting a review involves considering the following for each drug prescribed:

  • Does the drug have a valid and current indication? If not, consider stopping.
  • Is the drug in the list of drugs that are tolerated poorly in frail patients (see Panel, below left)? If yes, consider stopping.
  • Is the drug expected to give day-to-day symptomatic benefit (eg, painkillers)? Or is it important in preventing rapid symptomatic deterioration (eg, medication for left ventricular failure)? If yes, continue in almost all cases (only discontinue following specialist advice).
  • Is the drug replacing a vital hormone? If yes, continue.
  • Is the drug contraindicated or in the high risk drugs group (see Panel, below centre)? If yes, consider stopping.
  • If the drug is not covered by the questions above, refer to the drug effectiveness summary to help decide on balance of benefit and burden of the medication for that individual patient (see below).
  • If continuing the drug, consider if it is in an appropriate form and the least burdensome dosing?

High risk drugs

The following combinations are particularly high risk and should be avoided where possible

Non-steroidal anti-inflammatory drug (NSAID) :
•    Angiotensin converting enzyme (ACE) inhibitor or angiotensin 2 receptor blocker diuretic
•    Estimated glomerular filtration rate (eGFR) below 60
•    Diagnosis of heart failure
•    Warfarin
•    Age over 75 years and not taking a proton pump inhibitor

Warfarin :
•    Another antiplatelet (although sometimes appropriate)
•    NSAID
•    Macrolide
•    Quinolone
•    Metronidazole
•    Azole antifungal

Heart failure diagnosis :
•    Glitazone
•    NSAID
•    Tricyclic antidepressant

The drug effectiveness summary provides information on the expected effect of commonly prescribed drugs used for secondary prevention of diseases. It states the number needed to treat per annum to achieve a stated desired effect. It also lists how long a drug needs to be continued to have an effect. The aim is to help prescribers make an informed decision — in consultation with the patient or carer — on whether to continue a drug, particularly in cases where the patient has a shortened life expectancy.

How is it being implemented?

The guidance is for all prescribers in primary and secondary care. This includes GPs, prescribing support pharmacists, consultants and hospital pharmacists. Since most decisions about ongoing repeat prescribing are made by GPs, implementation of the policy is supported by a local enhanced service through which GPs are paid for conducting polypharmacy reviews. A computer tool is used to record the outcome of reviews and this also enables data on the reviews to be extracted for analysis.

The guidance was introduced in September 2010, so it is early days for data collection. But a detailed analysis is planned and initial back from prescribers has been positive.

Polypharmacy is a significant challenge in today’s NHS where patients frequently end up on 10 or more medicines. It is hoped that this guidance will help to improve the quality and safety of prescribing for frail patients who are most at risk from polypharmacy.

How can I find the guidance?

For details of how to get a copy of the guidance, see "How pharmacists can help combat polypharmacy in frail elderly patients".

 

Clare Morrison lead pharmacist, North Highland Community Health Partnership, on behalf of the NHS Highland Polypharmacy Action Group.

Citation: Electronicjuice URI: 11089493

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