Polypharmacy

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Getting it right for people prescribed many medicines

Guidance for healthcare professionals and healthcare organisations involved with medicines and patient care.

Read the full guidance HERE.

Shorter guidance for pharmacy teams and other audiences is available below.

Shorter guidance

For any audience

An introduction to polypharmacy An introduction to polypharmacy

Polypharmacy means taking more than one medicine

More and more people are taking more medicines

Polypharmacy can be complex to manage, and can sometimes become a problem. When a person takes many medicines, there's a larger risk for side-effects and interactions. The practicalities – taking all your medicines at the right time, and in the right way – becomes harder too.

Patients with long term conditions are especially vulnerable. Usually, they’re prescribed more medications, and it's important these are reviewed from time to time. 

Advice for:

Patients Healthcare professional Organisations

Tell your doctor, nurse or pharmacist if:

  • you're having problems with your medicines

 

  • you don't want to take them any more

 

  • you're taking over the counter medicines or supplements

Make sure your patients:

 

  • know what their medicines have been prescribed for

 

  • can and want to take the medicines you prescribe and supply

 

  • feel they can be honest about their medicines use

 

  • are involved in their medicines reviews and decisions about their care
  • empower pharmacists to manage polypharmacy issues

 

  • make sure your systems, culture and behaviours identify, review and support polypharmacy patients

 

  • keep the whole team up to date when medicines are started and stopped


For Pharmacy Teams

Learning outcomes Learning outcomes

This guide covers:

•    What polypharmacy is
•    Scale and complexity of polypharmacy,
•    Benefits of addressing polypharmacy and the risks of not doing so,
•    Considerations for addressing the issue of polypharmacy, and
•    Importance of shared decision making between healthcare professionals and people who take medicines (and their carers). 

This is intended to be a summary of the main document that The Royal Pharmaceutical Society has also produced ‘Polypharmacy: Getting our medicines right’.

Background Background

The reality is that more people are being prescribed more medicines than ever before, and increasingly more people taking a greater number of medicines – prescribed, purchased over the counter as well as herbal medicines and food supplements. 

Polypharmacy is when people are taking multiple medicines. This is often focussed on the elderly, but can also affect younger people and children, those from deprived backgrounds, people with multiple medical conditions, people with mental health problems and those with learning difficulties. It occurs in a range of health and social care settings, including hospitals, care homes, prisons, as well as those who are housebound or homeless. This can cause problems for people because of:

  • The number of tablets/capsules that they are required to take, 
  • The way they need be taken, 
  • How easy they are to swallow, 
  • Whether they can be taken all together,
  • The general process of ordering, and
  • Storing and managing many medicines.

Problematic polypharmacy is when:

  • The prescribing of medicines that are no longer clinically indicated or appropriate or optimised for that person,
  • Where the benefit of a medicine does not outweigh the harm, 
  • Where the combination of multiple medicines has the potential to, or is causing harm to the person, and
  • Where the practicalities of using the medicines prescribed to a person have become unmanageable or are causing harm or distress, for example where some medicines should be taken before food, others after food, some in the morning, some in the evening and others at multiple times during the day. 

Benefits of addressing polypharmacy Benefits of addressing polypharmacy

Addressing problematic polypharmacy, may result in more engaged people who are content with the medicines they have agreed to take because they have a better understanding why they are taking them. This will mean improved health outcomes, reduced risk of hospital admission and less medicines waste.
 

People Healthcare professionals Organisations

More engaged people

Better relationships between people and prescribers

Better compliance

Less waste

Improved health outcome

Reduced risk of hospital admission

More confident of patient engagement

Less waste

Improved health outcome

Reduced prescription volume

Less waste

Improved health outcome

Risks of not addressing polypharmacy Risks of not addressing polypharmacy

People Healthcare professionals Organisations

Increased risk of harm

Increased risk of non-compliance/medicine error

Increased risk of hospital admission

Increased risk of hospital admission

Increased medicines cost

Increased waste

Increased burden on repeat prescribing systems

Increased risk of hospital admission

Increased medicines cost

Increased waste

Increased burden on repeat prescribing systems

Considerations for improving problematic polypharmacy Considerations for improving problematic polypharmacy

People Healthcare professionals Organisations

Being open and honest about problems they have taking their medicines

Understand benefits and risks of taking and not taking medicines, and how to take them properly

Conducting high quality, person-centred consultations

Consider appropriateness of ALL medicines

Ensure appropriate monitoring processes are in place

Careful consideration before adding a medicine to a ‘repeat prescribing system’

Consider quantity of medicines already being taken before adding in a new medicine

Identification of people taking 10+ medicines

Identification of people taking high risk medicines

 

Healthcare professionals have a collective responsibility to address the many areas of polypharmacy.

Systems should be in place to identify those individuals who are taking 10 or more medicines and those taking high risk medicines, to ensure that correct monitoring and review processes are available. If these people can be engaged with, the above benefits may be realised.

Prescribing a new medicine to treat an adverse effect of an existing medicines should be a last resort, and all current medicines should be reviewed first.

Healthcare professionals should carefully manage and monitor people stopping medicines, so that it is done safely. Monitoring is essential and will help to alleviate the concerns that many healthcare professionals, and patients, have about stopping medicine – that the original problem may return, or there may be withdrawal/adverse events. This should be done as a patient-centred approach and with their agreement. It may be appropriate to consider non-medical treatment.

Polypharmacy and healthcare professionals Polypharmacy and healthcare professionals

If better conversations occur with people who will be taking medicines, so that they understand why they are taking their medicines and what to expect, this will improve adherence.

High quality medication review consultations should include the following:

  • Seeking the person’s (and/or their carer’s) perspective of their medicines and how they will take them,
  • Explaining what the medicine does (from a clinical perspective and from the person’s perspective),
  • Assessment of whether the medicines are essential or not,
  • Assessment of the person’s level of adherence to the medicines,
  • Assessment of the effectiveness (both clinical and cost effectiveness) of the medicines,
  • Assessment of the safety of the medicines, and consideration of whether a safer alternative may be available given the persons medicines record, and
  • Decision and actions regarding stopping or continuing the medicines.

If medicines reviews are conducted in line with best practice, then people should feel that:

  • When they leave the consultation, they know what they are taking the medicines for,
  • If they have any further questions, they know where to go to for help,
  • They have been listened to and their concerns have been heard and addressed, and
  • If they have further concerns about side effects or how to take the medicines properly that they can raise them.

The future The future

Prescribers and other healthcare professionals use the polypharmacy tools to identify those people at risk and know how to deal with the risk.

There is comprehensive guidance around safer systems for repeat prescribing.

Medicines reviews are always person-centred.

Prescribers are enabled to more confidently talk to people about safely stopping medicines.

The following are proactive triggers for reviewing the number of medicines that people are prescribed:

  • Identifying those individuals taking more than 10 (or 15) medicines,
  • A change in any evidence base for a medicine,
  • A person’s annual medicines review,
  • Identifying those individuals who take high risk medicines or are on a risky combination of medicines, and
  • The decision to make a medicine a ‘repeat medicine’.

The following are reactive triggers for reviewing the number of medicines that people are prescribed:

  • An unplanned admission to hospital,
  • A crisis, such as a change in family situation,
  • A serious incident (which may be linked to medication directly or indirectly, for example, a fall), and
  • A request for medicines to be managed via a Monitored Dosage System should be considered as a possible trigger for a medicines review.

Care should be taken with people transferring from one care setting to another that correct medicines are continued and those medicines that have been stopped remain stopped and that these details are well communicated.

For further information, please see the main document that The Royal Pharmaceutical Society has produced ‘Polypharmacy: Getting our medicines right’.

Case Studies

A patient story from the Scottish Therapeutics Utility A patient story from the STU

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.

Decision
Outcome
Risk
Meloxicam stopped
  • No difference to knee pain/movement
  •  Reduction of tablet burden
  • Medicine removed from repeat prescription
Reduction of GI bleed risk and hospital admission
Diltiazem dose reduction
  • Feels less tired
  • Reduction of tablet burden
  • Dose changed in prescription record
Reduction of falls risk and hospital admission
No need to prescribe PPI
  • Reduction of tablet burden
 

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

Introduction of new Primary Care Pharmacy Team in Caithness Primary Care Pharmacy Team in Caithness

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.

 

CASE STUDY IMAGE636809176133212559

 

Problematic Polypharmacy Examples Problematic Polypharmacy Examples

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.

Before review After Pharmacist review
Digoxin 125mcg OD Stopped in hospital-unsure why. To review
Rivaroxaban 20mg OD Stopped-Haematuria-Urology review
Bisoprolol 2.5mg OD Continue
Co-amilofruse 5mg/40mg 2 xOD Reduced and stopped by GP after recommendation. No clear indication of heart failure
Quinapril 30mg OD Reduced and stopped by GP after recommendation
Folic acid 5mg OD Review folate levels
Loratidine 10mg OD Seasonal-limit supply out of season
Sertraline 100mg OD Continue
Dihydrocodeine 30mg QDS/PRN Use with caution
Paracetamol 1g QDS/PRN Continue
Colecalciferol 20,000units OW Continue
Salbutamol inhaler Continue

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

Gastro-oesophageal reflux disease
Current meds:
-Ranitidine 300mg OM
-Omeprazole 20mg BD
-Lansoprazole 30mg OM
Recommend to initially stopping one PPI, preferably omeprazole (due to interaction with clopidogrel). If there is no flare up of symptoms please consider stopping lansoprazole and monitor management of GORD.
Omeprazole stopped
 
Prednisolone: Advised by rheumatology to reduce down and stop prednisolone due to Ms AC complaining of fluid retention in the legs. Currently she is not experiencing any fluid retention or SOB. I note that Furosemide 40mg was prescribed to manage the fluid retention.
Review and stop furosemide, the fluid retention is most likely due to long term administration of Prednisolone. Nil other cardiac issues
Review prednisolone dose/contact rheumatology team to discuss
Furosemide stopped
Dose reviewed by rheumatology
Methotrexate and Folic acid:
No recent bloods
Advised by rheumatology to increase folic acid from 3 times a week to 6 times a week to ease adverse effects of methotrexate
GP to review
Nil action by GP-reviewed by rheum
Bone protection
Calcium and Vitamin D: Currently taking Calcichew 500mg chewable tablets BD, in view of her condition Ms AC would benefit from vitamin D supplements as well.
Alendronic acid: Currently not taking as it is not included in the blister pack.
Check vitamin D levels and consider prescribing vitamin D supplement according to levels; may initially require a high dose and then switched to a maintenance dose.
Requires review; this needs to be taken correctly to minimise oesophageal irritation. Due to memory issue I would worry about this not being taken correctly on a weekly basis and therefore add to adverse effects.
Nil action taken by GP
Pain Currently prescribed Paracetamol 1g QDS in blister pack. However, only taking once a day when carers prompting. Unable to administer medications herself
Advise to initiate Buprenorphine 5mcg/hr patch and monitor for adverse effects. If managing well with the patch and providing relief considering increasing dose as appropriate to pain management.
Paracetamol switched to co-dydramol PRN
Eye drops Currently being prescribed preservative free (PF) preparations which are difficult for Ms AC to self-administer; there are no allergies documented to indicate why Ms AC requires the PF formulations.
Review formulation; the price for a generic Dorzolamide/Timolol preservative free is £25.99 and the price for generic Dorzolamide/Timolol eye drops is £1.97.
PF preparation stopped and changed to generic

 

Care Home and Housebound Multidisciplinary Polypharmacy Reviews Polypharmacy Reviews

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”

High Risk Medication High Risk Medication

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.

SHINE Project SHINE Project.

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’.

Polypharmacy Measurement Polypharmacy Measurement

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