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Polypharmacy Review
T. Lewis GP
Six principles
of medication review
• Patients should have a chance to raise questions and
highlight problems about their medicines
• Medication reviews seek to improve or optimise impact
of treatment for individual patients
• Reviews are undertaken in a systematic way, by
competent personnel
• Any changes resulting from reviews are agreed with the
patients
• Reviews are documented in patients’ notes
• The impacts of any changes in medication are monitored
Task Force on Medicines Partnership and The National Collaborative
Medicines Management Services Programme (2002) Room for review
Polypharmacy
‘The concurrent use of multiple medication items by an
individual.’
• Appropriate polypharmacy: defined as
prescribing for a complex condition or for multiple
conditions in circumstances where medicines use
has been optimised and where the medicines are
prescribed according to best evidence.
•
Problematic polypharmacy: defined as the
prescribing of multiple medications
inappropriately, or where the intended benefit of
the medication is not realised.
The King’s Fund (2013) Polypharmacy and medicines optimisation
Iatrogenic issues
Adverse drug reactions account for:
• 6.5% hospital admissions
• 4% of bed occupancy
Patients admitted have a median hospital stay of 8
days.
Drugs most commonly implicated:
Low-dose aspirin, diuretics, NSAIDs, warfarin
Pirmohamed M et al. (2004). Adverse drug reactions as a cause of admission
to hospital: prospective analysis of 18820 patients. BMJ 329:15-19
Are you comfortable signing the repeat
scripts?
Ultimate responsibility for every script
lies with whoever signs it.
How do you tackle a
polypharmacy review ?
T Lewis 2014
STOPP START criteria
STOPP (Screening Tool of Older Person's
Prescriptions) criteria identifies most commonly
prescribed potentially inappropriate medications
and
START (Screening Tool to Alert doctors to Right
Treatment).
Gallagher P et al. (2008). STOPP (Screening Tool of Older Persons’
Prescriptions) and START (Screening Tool to Alert Doctors to Right
Treatment): consensus validation. Int J Clin Pharmacol Ther. 46:72-83.
STOPP START
STOPP e.g.
– PPI full therapeutic dose
– Aspirin
– Duplicate medicines
– Benzodiazepines and 1+ fall in last 3 months
– Long-term, long-acting benzodiazepines
– NSAID long term for mild joint pain osteoarthritis
– Long-term opiates or neuroleptics in patients with
recurrent falls (1+ fall in last 3 months)
Gallagher P et al. (2008). STOPP (Screening Tool of Older Persons’
Prescriptions) and START (Screening Tool to Alert Doctors to Right
Treatment): consensus validation. Int J Clin Pharmacol Ther. 46:72-83.
Resources for STOPP START criteria
National Prescribing Indicators 2015–2016:
Supporting Information for Prescribers
Polypharmacy – Guidance for
Prescribing
Provides clinicians with a structured process of rationalising
patients’ medication, in particular for frail and elderly
patients. Includes:
• Summary charts
• Medicine-specific advice by BNF chapter
Adapted from Abertawe Bro Morgannwg University and
Hywel Dda Health Board documents, originally adapted
from NHS Highland, and from resources by Emyr Jones,
Aneurin Bevan University Health Board.
Polypharmacy – Guidance for
Prescribing
(Cont.)
SUMMARISES KEY CONSIDERATIONS FOR:
• Drug review process
• High-risk medications/combinations
• System-based factors (CV, GI etc)
• Patients with dementia
• Anticholinergic load/combinations
• Frailty
• Shortened life expectancy
• Practical guide to stopping medication including
transdermal opioids, antidepressants, benzodiazepines
• Number needed to treat for specific medicines
‘NO TEARS’
• Need/indication
• Open questions
•
•
•
•
•
Tests/monitoring
Evidence/guidelines
Adverse effects
Risk reduction/prevention
Simplification/switches
Lewis, T (2004) ‘Using the NO TEARS tool for medication review’ BMJ 329: 434
WeMeReC (2005) Bulletin: Medication Review for the 10 minute consultation
NO TEARS brief example
Medicine
•
•
•
•
•
•
•
•
•
•
Last collected
Calcium/Vit D3 bd 56
2 months ago
Betnovate 30 g
last month
Co-codamol 8/500 mg 2qds prn 200 last month
Amlodipine 5 mg od 28
last month
Gliclazide 80 mg bd 56
last month
Metformin 500 mg bd 56
last month
Tramadol 50 mg 2qds prn 100
last month
Accu-Chek
2 months ago
Omeprazole 20 mg od 28
last month
Glucosamine od 28
last month
TL 2014
NO TEARS brief example
Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28;
co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56;
metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100;
Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28
Need and Open
• Patient’s view of regular medicines?
• “What do you take each day?”
• “I realise a lot of people don’t take all their
tablets. Do you have any you don’t like?”
• Calcium taken? PPI still needed?
T.L. 2014
NO TEARS brief example
Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28;
co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56;
metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100;
Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28
Tests
Diabetes/hypertension monitoring, osteoarthritis
functional impact
Evidence
Diabetes - consistent with current guidance
Osteoarthritis - tramadol? Stop glucosamine
Dermatology - steroid on repeat, no emollient
T.L. 2014
NO TEARS brief example
Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28;
co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56
metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100;
Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28
Adverse Events steroid on repeat
Risks co-codamol + tramadol
Simplification/synchronisation/switch/stop
stop glucosamine, switch glucose testing strips?
T.L. 2014
Combine with a basic approach?
• STOP
• SORTED
• SPECIAL
T. Lewis 2014
Stop, Sorted, Special
Stop
• The obvious ones
–
–
–
–
–
–
–
left out when patient lists meds taken
not collected/expired
infrequent requests/low % use
short course completed
shouldn’t be on repeat
hospital letters stated stop
condition resolved
T.Lewis 2014
Stop, Sorted, Special
Has been assessed and monitored within the last
12 months, e.g.
- Chronic disease clinic
- Hospital review
- and no outstanding concerns
T. Lewis 2014
Stopped, Sorted, Special - Priorities
Consider medicines recently highlighted:
–
–
–
–
–
–
High-risk medicines
Practice priorities
AWMSG National Prescribing Indicators
Local comparators
MHRA alerts
NICE
T. Lewis 2014
Six principles
of medication review
• Patients should have a chance to raise questions and
highlight problems about their medicines
• Medication reviews seek to improve or optimise impact
of treatment for individual patients
• Reviews are undertaken in a systematic way, by
competent personnel
• Any changes resulting from reviews are agreed with the
patients
• Reviews are documented in patients’ notes
• The impacts of any changes in medication are
monitored
Task Force on Medicines Partnership and The National Collaborative
Medicines Management Services Programme (2002) Room for review