Polypharmacy

An 88 year old man at a GP Practice was identified from a Scottish Therapeutics Utility (STU) report as being on a high risk medicine combination of low dose Aspirin and Meloxicam. This is a combination which increases the risk of bleeding. Clinically, it is recommended to prescribe an acid blocking medicine (PPI) if this combination has to continue in patients over 75 years old to reduce this risk.

The patient was also taking a combination of medicines for hypertension and ischaemic heart disease which he had been on for around 15 years which, as a patient ages, can reduce pulse rate to a level that can increase the risk of dizziness and falls. Therefore doses should be reviewed and may need reduced.

The patient had been attending for regular blood pressure checks but there was no note in the patient record of a pulse being measured. The patient was due for a repeat BP so the pharmacist requested the practice nurse to also take a pulse. The pulse was 58 (recommended to be above 60 to avoid risk of dizziness and falls).

The pharmacist arranged with the patient to visit him at home to review his medicines, symptoms and to repeat BP and pulse. Patient lives with wife independently with no social input.

Pulse was 52, BP well controlled. The patient reported feeling more tired over the last 3 months. He took the Meloxicam for his sore knee but was willing to try and stop to measure whether there was any difference but was keen to be able to keep bowling on a Wednesday!

Post visit discussion with the GP - agreed to reduce the dose of one of his rate controlling medicines and follow up with patient.

Conclusion

Modest cost saving of £60/year – correlates with national figure of £50-200 per patient who has a medicine review by a pharmacist

Reduction of risk of hospital admission - national hospital admission and cost avoidance figure of £200-1700 per100 of population who have a medicine review by a pharmacist

In 2015, building on previous work NHS Highland restructured our primary care pharmacy team in Caithness. This means frail older patients in care homes and in their own homes are seen regularly by specialist Primary Care

Clinical Pharmacists.  In two GP practices, Advanced Pharmacist Practitioners are now responsible for medicines management.

These pharmacists are members of local integrated teams. These are multidisciplinary health and social care teams – nurses, carers, allied health professionals, pharmacists (and with input from doctors) – who have a caseload of people who need additional support to live independently.

The pharmacists’ roles in the teams is to:

• Review patients who have just been discharged from hospital to see how they are getting on with changes to medicines
• Review patients who are at risk of hospital admission to see if any medicines can be adjusted to reduce the risk of admission
• Provide six monthly medication review for every person receiving care at home, and support the initiation of new care at home packages
• Provide six monthly medication review for every resident in care homes.
• Provide polypharmacy reviews for patients identified by GP practices
•  Review patients who have had a fall to see if there is a medicines-related cause
• Respond to acute medicine requests, which are the daily requests practices get from patients for medicines that aren’t on their repeat list.
•  Provide intensive medicines support, usually titrating doses.
• They also provide medicines advice to the practice as a whole

The Specialist Clinical Pharmacist works wherever the patient is – follow the patient, because very often they see the same patient in hospital and at home. The consistency of support no matter where the patient is ensures that the patient’s long-term pharmaceutical care needs can be addressed. Often it’s difficult to tackle everything at once – particularly if the patient is acutely unwell in hospital – so the pharmacist will write a pharmaceutical care plan and address all aspects of polypharmacy over a longer period as they can see that patient both in the hospital and at home

Data collected across the two practices who were first involved calculated time saving per 5000 patients.

• Pharmacist input 28 hrs / week/ 5000 patients > 1260 hours / year
• GP time saved 960 hours

The work in Caithness building on previous work has kept increase in prescription items dispensed down.  An impressive finding on the background of an increasingly ageing and complex population.

Example One

Mrs DM 93 year old with a past medical history of atrial fibrillation, depression, asthma chronic kidney disease stage 3 and multiple falls, Alzheimer’s. Patient is a frequent faller and also has low BP readings 102/60-she does not experience any dizziness, however the low BP is a problem irrespective of symptoms-increases risks of falls.

Advice provided to GP:

BP remains significantly low, BP reading 102/60. No complaints of any signs of symptoms contributed from the low BP; however this does put her at risk of falling. She is on several anti-hypertensive medications which could be reviewed.

Currently taking Quinapril 30mg OD, start by reducing dose to 10mg. If Ms DM remains well after this reduction, next step would be to reduce to Co-amilofruse 5/40mg to 1 tablet a day from 2 tablets a day. If there’s no recurrence of oedema/dyspnoea after a couple of weeks then it could be further reduced to a half, and then maybe stopped. And if she’s still hypotensive after all that then consider stopping the quinapril.

Example Two

80year old lady with urinary incontinence, heart failure and osteoporosis

Duloxetine 40mg OD, Mirabegron MR 50mg OD, Solifenacin 10mg OD, Losartan 50mg OD, Levothyroxine 150mcg OD, Adcal D3, Atorvastatin 40mg OD

Patient on three different anticholinergics, no clear indication as to reasoning behind why all three prescribed.

-Duloxetine 40mg BD (please note if it is decided to stop this medications please do so gradually to avoid withdrawal effects)

-Solifenacin 10mg OD (Anticholinergic-more prone to adverse effects in the elderly)

-Mirabegron MR 50mg OD

Although they all have different mechanisms of actions it is putting Ms BT a greater risk of recurrent falls and adverse effects. As well as increased pill-burden.

Example Three

Ms AC 88 year old lady is unable to manage medications alone due to polypharmacy, declining memory and stockpile of medicines

The 2012 the National Polypharmacy Guidance was the basis for a Lothian-wide polypharmacy reviewproject. Over a 4 year period 9,199 polypharmacy reviews were carried out by the pharmacy team. This resulted in 10,813 medicines being stopped (an average 1.2 medicines per patient) of which 25% were high risk medicines.In addition 2,436 doses were reduced, 384 doses increased, 1,278 medicines started and 753 medicines switched. The average cost saving per patient was £100 per year.This project had its limitations in that all reviews were paper-based and relied on GPs acting on recommendations made by the pharmacist (70% uptake).

The pharmacy team, in line with the ethos of the national guidelines for polypharmacy review, progressed this work to a multidisciplinary team (MDT) setting to further improve the pharmaceutical care, and reduce the risk of medicines-related harm, in the frail elderly population. The MDTconsisted of a Consultant geriatrician, a registrar, GP in training, a GP, pharmacists and care home staff.The MDT reviews resulted in an increase in the cost saving per patient per year (£560 per patient per year in one care home) as GPs were generally more confident in stopping inappropriate medicines with consultant input.These meetings proved to be anexcellent environment for learning and highlighting the application of the national polypharmacy guidance. This MDT approach however was only occurring in a small number of care homes in South Edinburgh.

Based on the success of these MDT polypharmacy reviews and the increase in the pharmacy workforce withinprimary care the SW pharmacyteam, with approval from the 17 SW Edinburgh GP practices, agreed to work towards annual MDT reviews of all 11 Care Homes within the locality.In addition the SW locality GP’s agreed to trial extending this MDT polypharmacy review approach to all housebound patients greater than 75 years of age and on greater than 10 medicines on repeat. Not all GPpractices were responsible for a care home so extending the MDT reviews to thehouseboundmeant all practices within SW Edinburgh could gain experience in polypharmacy review in the frail elderly.An invest to save project bid was successful and funding was received for for a six month period.

Results: The care home reviews are on target for an annual reviewas 5 out the 11 care homes were reviewed in the six month period.

In addition a total of 7 GP practices had a multidisciplinary review of their frail elderly housebound patients ( housebound results: 169 patients reviewed, 162 medicines stopped of which 40% were high risk, 113 dose/formulation changes and 20 medicines started)

In summary the MDT polypharmacy reviews have contributed to changing the culture of prescribing in the frail elderly within primary care.A quality improvement bid has also been submitted by one of the practices to answer the question “Does targeting polypharmacy reviews in the frail elderly reduce admissions to hospital?” 

These quotes  sum up how the project went beyond just polypharmacy reviews:

GP

“I thought it was an excellent opportunity to have protected time to properly review and rationalise all the medications from an evidence based perspective, with the expert help of the geriatrician and yourselves. Would be very happy to have further sessions as it will improve patient safety in the longer term.”

 Geriatrican:

“I’ve found this a really good project and I’ve really enjoyed getting out and meeting some of the pharmacists and GPs. I think it goes beyond polypharmacy in that it is bridging links between secondary and primary care”

Pharmacist:

 “although my housebound review savings have worked out at £173.97 per patient per year I really feel that this figure  doesn’t matter- as we  have stopped some drugs that could cause harm and that is just not quantifiable. Also some visits have been really worthwhile just for an opportunity for the patients to discuss their medicines”

Download case study HERE

Download case study HERE

West Hampshire CCG experienced a serious event with a person who was prescribed the high-risk medicine amiodarone. The person, although being monitored, developed pulmonary toxicity. The incident triggered a CCG review of amiodarone prescribing. 480 people were found to be taking amiodarone, but the reasons for the medicine being prescribed were not always clear. All people taking amiodarone were offered a review by a cardiologist and 32% were found not to need this medicine and as a result the medicine was stopped. Amiodarone is a high-risk medicine and should only be prescribed where there is a clear clinical indication as part of an ongoing treatment plan and processes for routine monitoring must be robust and measurable.

Mrs E was taking 11 medicines – alendronate, simvastatin, aspirin, perindopril, bisoprolol, paracetamol, donepezil, memantine, quetiapine, haloperidol (when required) and docusate.

She had advanced stage dementia and was bed-bound.  She was very agitated and would often be given a dose of haloperidol.  Her medicines were either liquid or crushed and suspended in water. Administration of medicines was challenging and may not have been completely in line with best practice. Mrs E’s medicines were reviewed by the pharmacist and a meeting arranged with daughter, GP and care home nurse. This was done at Mrs E’s bedside.

It was agreed to stop alendronate, simvastatin, perindopril, bisoprolol (BP was quite low). The GP was worried about ‘meddling’ with the psychiatric medicines. Over about two weeks Mrs E settled and was less agitated. The pharmacist spoke with Mrs E’s consultant (an older age psychiatrist) and together reduced and stopped quetiapine, memantine and donepezil. She no longer was requiring haloperidol so over time that was stopped.

Her daughter reported that ‘Mum is looking much more peaceful, responsive to her being there and even the odd smile’.

Patients within a large urban practice in Dorset, ≥ 75 years old with ≥ 10 regular medicines (BNF chapters 1-4 and 6-10) were identified using the NHS Business Service Authority Polypharmacy prescribing comparators. Patients who were palliative, housebound, lived in a care home or with dementia were excluded following GP validation. Patients were sent a letter from their personal GP inviting them to attend a 30-minute consultation with a clinical pharmacist prescriber employed by the practice. The consultations were structured around the NO TEARS tool for medication review and medicines at high risk of causing preventable drug-related admissions to hospital were targeted. The age and frailty status of patients, number of medicines pre- and post- consultation, and the nature of medicines optimisation decisions were recorded. Results:

• 85 out of 17,000 (0.5 %) patients were receiving ≥ 10 medicines
• The median age of the 32 eligible patients was 83.5 (range 75 – 95), male to female ratio 47:53% with a median Rockwood clinical frailty score of 4 (range 3–6)
• 30/32 (94%) patients had their medication regimes optimised
• 34/48 patients (71%) patients replied to the letter and were seen by the clinical pharmacist, 2 were excluded as they were taking < 10 medicines
• 28/32 (88%) patients completed the satisfaction survey, and all rated the overall consultation as very good to outstanding (median score 6 = excellent). All elements of the survey had a median score of 6.

(Impact of practice based clinical pharmacist led medication reviews on ambulatory patients with hyper polypharmacy)