Alpana Mair
@AlpanaMair
Head of Effective Prescribing and Therapeutics, Scottish Government; EU Project Coordinator, SIMPATHY
As life expectancy grows, so too does the number of people who use multiple medications for extended periods. This means health providers must develop complex care plans for often vulnerable patients. Compounding the problem of polypharmacy in treating multiple morbidities, most medical research, guidelines, and contractual agreements focus only on single targets for single disease states.
While we often consider pharmacovigilance in the context of single medicines, polypharmacy experiences highlight the need to think about it in the context of multiple morbidities. Put simply, patients taking more medicines can face increased risk of adverse effects. Also, as people age, changes in physiology, in particular renal and hepatic impairment, can increase the risk of adverse effects from medications.
The aim of addressing polypharmacy is to identify those patients at greatest risk of harm and to set a medication regimen that is tailored to their changing needs and expectations.
Globally, with up to 11% of unplanned hospital admissions are attributable to harm from medicines and more than 70% of these are elderly patients on multiple medicines, there are significant opportunities to reduce the burden this presents with timely and effective interventions.
Polypharmacy is often beneficial. For example, secondary prevention of myocardial infarction requires the use of at least four different classes of drugs (antiplatelet, statin, ACE inhibitor, beta blocker). But whether or not polypharmacy is appropriate depends on a careful assessment of many different factors.
In this context, the EU-funded project SIMPATHY conducted a two-year study of polypharmacy management in Europe, from which it identified six key recommendations:
- Use a systems approach that has multidisciplinary clinical and policy leadership.
- Nurture a culture that encourages and prioritises the safety and quality of prescribing.
- Ensure that patients are integral to the decisions made about their medicines and are empowered and supported to do so.
- Use data to drive change and measure outcomes.
- Adopt an evidence-based approach with a bias towards action.
- Utilise, develop, and share tools to support implementation.
The issue of polypharmacy is an international concern. For example, the third WHO Global Patient Safety Challenge: Medication without Harm, includes appropriate management of polypharmacy as a key area. This polypharmacy guidance also addresses the use of high-risk medicines and ensures that information on appropriateness of medicines is shared across transitions of care.
Appropriate polypharmacy requires consideration at any point of care, but there are five clear stages which should be used as a trigger:
- Prescribing (and risk assessment)
- Medication review
- Dispensing and administration
- Communication and patient engagement
- Medication reconciliation (at care transitions).
NHS Scotland is one of only five EU authorities with national guidance for polypharmacy management aimed at improving patient outcomes and the cost-effectiveness of healthcare. The Scottish Polypharmacy guidance includes a seven-step process to review medication appropriateness and the authority has even released an app to support the inclusion of patients through shared decision making.
Scottish guidance for polypharmacy review – 7 steps
- What matters to the patient?
- Identify essential drug therapy.
- Does the patient take unnecessary drug therapy?
- Are therapeutic objectives being achieved?
- Is the patient at risk of ADRs or suffering actual ADRs?
- Is drug therapy cost-effective?
- Is the patient willing and able to take drug therapy as intended?
Typical polypharmacy case study
Mr. P is an 80-year-old man on five medications following a heart attack (beta blocker, ACEI, diuretic, statin, aspirin); metformin for diabetes; a bisphosphonate for osteoporosis; and calcium, vitamin D, and paracetamol when needed for his osteoarthritis. He is well controlled on this regimen. Mr. P then develops neuropathic pain and consults his GP, who suggests amitriptyline. Mr. P says he doesn’t want it, but the GP sends it anyway. He does not take the amitriptyline and tells the pharmacy he doesn’t want it. A couple of months later, Mr. P’s medications, including the amitriptyline, are put in a compliance box. Mr. P complains of dizziness. When his daughter questions the presence of amitriptyline, both the pharmacy and the GP explain it has been on his list for the past four months and he should take it. The next day, Mr. P falls on the street requiring help. He is shaken but able to go home. The next day, he falls and is admitted to hospital. His medications are reviewed, and the amitriptyline is stopped. Mr. P has no more falls, but his confidence is shaken.
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