POLYPHARMACY & MEDICINES OPTIMISATIONPolypharmacy is a key Hot Topic which is closely linked with the other key concepts of multimorbidity, frailty and falls. Reducing the treatment burden for patients with multimorbidity is one of the key objectives of the new NICE Multimorbidity Guideline and multimorbidity and polypharmacy are new, key therapeutic topics for NICE NICE 2017, KTT18 Multimorbidity & Polypharmacy

As for multimorbidity, polypharmacy is predominantly but far from exclusively a problem for elderly people. A frail ageing population, lower thresholds for diagnosis and treatment of chronic disease and the proliferation of single disease guidelines in patients with multimorbidity has led to a huge increase in patients on multiple medications with great potential for harm and often little evidence of benefit. Adverse drug reactions account for 8% of all hospital admissions, figures rising to 17% in the over 65s (figures from NHS England data 2017). And yet appropriate polypharmacy can be evidence based, effective and improve outcomes.

► How can we manage polypharmacy better?NICE published in 2015 a new guideline on Medicines Optimisation and the excellent PoIypharmacy Guidance 2015 from NHS Scotland has also been updated (this guidance comes with an excellent NHS Scotland Polypharmacy App.

The challenge for us is to know how best to prescribe appropriately. Back in 2013 the Kings Fund Polypharmacy Guideline stressed that we should consider polypharmacy as being either appropriate or problematic.

Appropriate polypharmacy, where medicines have been optimised and are prescribed according to the best available evidence

■ For many patients appropriate polypharmacy will extend life expectancy and qualityof life e.g. type 2 diabetes complicated by hypertension and coronary heart disease

Problematic polypharmacy, where multiple medications have been prescribed inappropriately leading to:

■ Increased risk of interactions, adverse drug reactions, an unacceptable ‘pill burden’for patients, poor compliance and impaired quality of life for patients and wastage

■ There is increasing evidence of prescribing errors, high risk prescribing and adversedrug events which are a common cause of unplanned hospital admissions

■ Problematic polypharmacy is particularly seen in people with frailty

What is clear is that we need to prescribe more safely and also develop our deprescribing skills.

Prescribing safely means taking patient factors, such as frailty which greatly increases the risk of adverse reactions, into account as well as medication factors. For deprescribing the guidelines provide great tools to provide comparative benefits of medications, to help choose which drugs we should stop. There is emerging evidence that in patients with multimorbidity and older people deprescribing may be linked to improvements in quality of life and survival BMJ2014;349:g7013

What is also clear is to implement this, we need time and to broaden the primary care skill mix. In line with GP Forward View, patient facing clinical pharmacists are being introduced into primary care teams with the hope and expectation that they shall be able to implement a lot of this work.

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Polypharmacy Guidelines ►The NHS Scotland Polypharmacy Guideline NHS Scotland Polypharmacy Guideline 2015

This excellent Scottish guidance aims to help prescribers rationalise complex medication regimens (NB we much prefer it to the NICE guideline as it is much more practical and applicable). It gives practical guidance for what to cover at a complex drug review, and considerations before stopping drugs. It also gives guidance (using NNTs) on which drugs are most effective, helping patients and prescribers to decide which ones should stop. They have produced an excellent, free Polypharmacy App The guideline proposes a 7 stage process to consider when doing a medication review, and to guide you in deciding which is most appropriate medication to stop.

Prescribing in frail, elderly patients

Drugs which have anticholinergic effects are well recognised as being particularly problematic in frail adults. New research Age Ageing 2014;43:604 confirms that they have a significant adverse effect on physical (including falls) and cognitive function, and a trend towards increased mortality.

The NHS Scotland Polypharmacy Guideline 2015 includes a Modified Anticholinergic Risk Scale. We can see that many drugs considered safe e.g. antihistamines, prochlorperazine etc can have significant anticholinergic effects which in combination with others could potentially be harmful.

Modified Anticholinergic risk scalethe higher the number the greater the anticholinergic effect and the greater the risk

Category 1 Category 2 Category 3Haloperidol, quetiapine, mirtazapine, paroxetine, trazodone, ranitidine, lofepramine

Clozapine, notryptiline, olanzapine, baclofen, cetirizine, loratadine, cimetidine, loperamide, prochlorperazine, tolteridone, sertraline

Chlorpromazine, amitryptiline, imipramine, chlorpheniarmine, oxybutynin, hydroxyzine

NHS Scotland Polypharmacy Guideline 2015

7 steps approach to a medication review:

• Identify the aims and objectives of the drug therapy

• Identify essential drug therapy

• Does the patient take unnecessary drug therapy?

• Are therapeutic objectives being achieved?

• Is the patient suffering from ADRs or at risk of them?

• Is the drug therapy cost-effective?

• Is the patient willing and able to take the drugs as indicated?

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►NICE Guideline NICE, NG5 Medicines Optimisation 2015

The 2015 NICE Guideline uses the Kings Fund definitions of appropriate or problematic polypharmacy. The guideline mostly seems to be focussed on health and social care organisations and care delivery, and is less practical for GPs than the Scottish guidelines. Nonetheless, some important recommendations are made, not least the use of the PINCER intervention and the STOPP/START tool to guide prescribing in older people from NHS Cumbria

NICE Medicines Optimisation Guideline, Key Points

NG5 Medicines Optimisation 2015

• Undertake medicines reconciliation for all people who have been discharged from hospitalor another care setting (this is when prescribing errors are most likely)

○ This is the active process of identifying an accurate list of current meds and comparingit with their prescribed list, recognising and correcting discrepancies

• Carry out a structured, medication review in all patients with polypharmacy, taking intoaccount

○ The person’s, and their family members or carers when appropriate, views○ All OTC and complementary medicines○ The relative safety and efficacy of the medicines○ Whether the person has had any adverse drug reactions

• Consider applying the principles of the PINCER intervention to reduce adverse drug reactions○ Use dedicated, pharmacist led IT support system with GP outreach, support and follow

up. See The PINCER Audit Tool○ Consider using a risk screening tool e.g. STOPP START Toolkit

■ the tool in older people to identify potential medicines-related safety incidents■ This gives simple guidance on drugs to preferentially stop or start

• With people with long term conditions consider using an individualised, documented self- management plan

• Offer people the opportunity to make decisions about medicines using patient decision aids• Consider using clinical decision support software

As a supplement to this guideline NICE have published a key therapeutic topic on multimorbidity and polypharmacy NICE KTT18, 2017 which includes an updated table of resources.

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NB Quality Improvement Ideas: Polypharmacy• Identify high risk patients, those receiving 10 or more regular medications (applies to 1 in 6

over 65)○ Undertake a ‘medicines optimisation’ review of these patients, using the NHS Scotland

‘7 steps’ above or the NHS Wales tool at Drug Review Tool Page 2• In frail elderly patients use the anticholinergic risk scale to help safer prescribing• In older people guide prescribing using the STOPP START Toolkit• The PINCER trial demonstrates that pharmacist-led interventions make prescribing safer in

primary care? commissioning idea• Consider using the The PINCER Audit Tool to help identify patients at risk of adverse drug

reactions• Ensure a system is in place for medicines reconciliation after patients are discharged• For patients at risk of acute kidney injury given them information on ‘sick day guidance’ of

medicines to stop when they are unwell e.g. diuretics, ACE drugs, metformin and NSAIDs

Additional resources:

NICE 2017, Table of Polypharmacy resources

NHS Polypharmacy & Deprescribing Resources

Seven Steps to Managing Polypharmacy

NHS England Medicines Optimisation Dashboard

NHS Wales Guidance on stopping medication in the elderly

NHS Scotland Polypharmacy Guideline 2015

NHS Scotland EXCELLENT Polypharmacy App

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