Download Polypharmacy, medicines optimisation and clinical decision support

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Problematic Polypharmacy
Dr Martin Duerden
[email protected]
#PCPA16
polypharmacy, n.
• The use of multiple drugs or medicines for several
concurrent disorders (now esp. by elderly patients), often
with the suggestion of indiscriminate, unscientific, or
excessive prescription
Google Ngrams, Oxford English Dictionary
Medication use is increasing
Prescribing Cost Analysis, England
Prescribing is increasing
Guthrie et al. BMC Medicine (2015) 13:74
DOI 10.1186/s12916-015-0322-7
A nation of pill takers? Health Survey for England, 2013
Report 2015: www.hscic.gov.uk/catalogue/PUB16076
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Estimated and projected age structure of the United Kingdom
population, mid-2014 and mid-2039 (Report, October 2015)
www.ons.gov.uk/ons/rel/npp/national-population-projections/2014-based-projections/index.html
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Multimorbidity: Number of chronic disorders by age group
Barnett K et al. Lancet 2012; 380: 37-43.
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Comorbidity of 10 common conditions among
UK primary care patients
Guthrie B et al. BMJ 2012;345:e6341
Age and multimorbidity
Payne RA, Eur J Clin Pharmacol 2014
Defining polypharmacy - quantitative
• Specific numeric thresholds
• Widely used – can aid research
• Simple and easy to implement
• “Four or more” – QOF (but now the norm!)
• Which drugs? Short vs. long term? OTC?
• Polypharmacy is a continuum
• Ignores appropriateness
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Defining polypharmacy - qualitative
• Appropriate polypharmacy is prescribing for
an individual for complex conditions or for
multiple conditions in circumstances where
medicines use has been optimised and the
medicines are prescribed according to best
evidence. The overall intent for the
combination of medicines prescribed should
be to maintain good quality of life, improve
longevity and minimise harm from drugs.
• Problematic polypharmacy is where
multiple medications are prescribed
inappropriately, or where the intended benefit
of the medication is not realised, or where
one or more of the following apply…
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Problematic Polypharmacy…where one
or more of the following apply…
• The drug combination is hazardous because of
interactions.
• The overall demands of medicine-taking, or ‘pill burden’,
are unacceptable to the patient.
• These demands make it difficult to achieve clinically
useful medication adherence (reducing the ‘pill burden’
to the most essential medicines is likely to be more
beneficial).
• Medicines are being prescribed to treat the side effects
of other medicines where alternative solutions are
available to reduce the number of medicines prescribed.
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Why is it so problematic?
Guidelines everywhere…
2008
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Prostate cancer
Osteoarthritis
Surgical management of OME
Irritable bowel syndrome
Antenatal care
Diabetes in pregnancy
Prophylaxis against infective
endocarditis
Perioperative hypothermia
(inadvertent)
Type 2 diabetes
Lipid modification
Stroke
Respiratory tract infections
Induction of labour
Familial hypercholesterolaemia
Attention deficit hyperactivity
disorder (ADHD)
Chronic kidney disease
Surgical site infection
Metastatic spinal cord
compression
2009
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Medicines adherence
Antisocial personality disorder
Borderline personality disorder
(BPD)
Rheumatoid arthritis
Breast cancer (early & locally
advanced)
Breast cancer (advanced)
Schizophrenia
Critical illness rehabilitation
Diarrhoea and vomiting in
children under 5
Glaucoma
Coeliac disease
Type 2 Diabetes - newer agents
Low back pain
When to suspect child
maltreatment
Depression in adults
Depression with a chronic
physical health problem
2010
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Venous thromboembolism reducing the risk
Donor breast milk banks
Unstable angina and NSTEMI
Chest pain of recent onset
Neuropathic pain pharmacological management
Lower urinary tract symptoms
Neonatal jaundice
Constipation in children and
young people
Alcohol-use disorders: physical
complications
Chronic obstructive pulmonary
disease
Bacterial meningitis and
meningococcal septicaemia
Delirium
Metastatic malignant disease of
unknown primary origin
Motor neurone disease - noninvasive ventilation
Barrett's oesophagus - ablative
therapy
Hypertension in pregnancy
Chronic heart failure
Transient loss of consciousness
in adults and young people
Pregnancy and complex social
factors
Nocturnal enuresis - the
management of bedwetting in
children and young people
Sedation in children and young
people
2011
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Anxiety
Anaemia management in people
with CKD
Alcohol dependence and harmful
alcohol use
Food allergy in children and
young people
Tuberculosis
Colonoscopic surveillance for
prevention of colorectal cancer
Diabetic foot problems - inpatient
management
Psychosis with coexisting
substance misuse
Lung cancer
Ovarian cancer
Common mental health disorders
Hip fracture
Peritoneal dialysis
Stable angina
Hypertension
Autism in children and young
people
Multiple pregnancy
Hyperglycaemia in acute
coronary syndromes
Colorectal cancer
Caesarean section
Self-harm (longer term
management)
Anaphylaxis
Organ donation
Service user experience in adult
mental health
2012
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Epilepsy
Patient experience in adult NHS
services
Infection control
Opioids in palliative care
Acute upper GI bleeding
Autism in adults
Sickle cell acute painful episode
Venous thromboembolic diseases
Spasticity in children and young
people
Osteoporosis fragility fracture
Lower limb peripheral arterial
disease
Urinary incontinence in
neurological disease
Antibiotics for early-onset
neonatal infection
Headaches
Neutropenic sepsis
Crohn’s disease
Psoriasis
Ectopic pregnancy and
miscarriage
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Potentially serious drug-drug interactions between drugs recommended by clinical
guidelines for three index conditions and drugs recommended by each of other 11 other
guidelines. Dumbreck et al. BMJ 2015;350:bmj.h949
Inappropriate prescribing in Ireland
Moriarty F, BMJ Open 2015
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So what can we do?
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Defining medicines optimisation
NICE, Medicines Optimisation Guideline NG5, March 2015.
• ‘A person-centred approach to safe and effective
medicines use, to ensure people obtain the best
possible outcomes from their medicines.
• Applies to people who may or may not take their
medicines effectively.
• Shared decision-making is an essential part of
evidence-based medicine, seeking to use the
best available evidence to guide decisions about
the care of the individual patient, taking into
account their needs, preferences and values.’
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Medication review
Medicines Optimisation, NG5, March 2015
'a structured, critical
examination of a
person's medicines with
the objective of reaching
an agreement with the
person about treatment,
optimising the impact of
medicines, minimising
the number of
medication-related
problems and reducing
waste'
Barnett N, et al, 2015
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Alternatives - “social prescriptions”
• Exercise (on prescription)
• Arts (on prescription)
• Educational programmes
• Social contact for isolation and loneliness
• Links to voluntary organisations
• Community activities
• Alleviating boredom
• Consider alcohol problems
• etc.
Where to start… ‘high risk’ polypharmacy
• A pragmatic approach?
• All patients with 10 or
more regular medicines
• Patients receiving 4 to 9
regular medicines and
• ≥ potentially inappropriate
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prescribing criteria
Interaction or
contraindication
Record of adherence
problems
Only one major diagnosis
recorded in notes
Receiving end-of-life care
When to stop….. deprescribing
“The process of
withdrawal of an
inappropriate
medication, supervised
by a health care
professional with the
goal of managing
polypharmacy and
improving outcomes”
Reeve E, Br J Clin Pharmacol 2015
• Patients may be
resistant, or supportive
• Clinicians uncertain
• ‘Giving up’ on patients
• Disapproval of
colleagues
• Lack of evidence or
safety
• Inconsistent with
guidelines
Frailty and potentially problematic
polypharmacy – upcoming NICE Guideline
on multimorbidity
• Using frailty to target a “tailored approach”
to managing multimorbidity
• gait speed, timed “get up and go”
• self-reported health status
• PRISMA-7
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General issues
• Identify the concerns, preferences and
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wishes of patients and carers.
Does the patient know what each
medicine is for and why they are taking
it?
Ask about the use of over-the-counter
medicines, vitamins and herbal
remedies.
Is the patient frail? If so, consider which
drugs may be problematic.
Do end-of-life considerations apply?
Are there ethical issues about
withholding care?
Consider discussing with other clinicians
and develop a clinical management plan
to aid continuity.
PRISMA-7 Questions
• Are you more than 85 years old?
• Are you male?
• In general do you have any health
problems that require you to limit your
activities?
• Do you need someone to help you on a
regular basis?
• In general, do you have any health
problems that require you to stay at
home?
• If you need help, can you count on
someone close to you?
• Do you regularly use a stick, walker or
wheelchair to get about?
A score of ≥3 positive responses suggests
the need for further clinical review.
www.goldstandardsframework.org.uk
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Shared-decision making and PDAs
Medicines Optimisation, NG5, March 2015
‘Many people wish to be active
participants in their own healthcare,
and to be involved in making
decisions about their medicines.
Patient decision aids can support
health professionals to adopt a
shared decision-making approach in
a consultation, to ensure that
patients, and their family members or
carers where appropriate, are able to
make well-informed choices that are
consistent with the person's values
and preferences.’
Blood glucose lowering: not too little, not too much
Currie CJ, et al. Lancet 2010;375:481–9
Adjusted hazard ratios for all-cause mortality by HbA1c deciles in people
given metformin plus sulphonylurea (A) and insulin-based therapy (B)
Metformin plus sulphonylurea
Insulin-based therapy
Vertical error bars show 95%CIs, horizontal bars show HbA1c range. Red circle =
reference decile. *Truncated at lower quartile. †Truncated at upper quartile
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Example: HbA1c ‘flexible’ targets
NICE Guideline 28, December 2015
• Consider relaxing the target HbA1c level on a case-by-
case basis, with particular consideration for people who
are older or frail:
• who are unlikely to achieve longer-term risk-reduction
benefits, for example, people with a reduced life
expectancy
• for whom tight blood glucose control poses a high risk of the
consequences of hypoglycaemia, for example, people who
are at risk of falling, people who have impaired awareness
of hypoglycaemia, and people who drive or operate
machinery as part of their job
• for whom intensive management would not be appropriate,
for example, people with significant comorbidities
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NICE patient decision aid for type 2 diabetes
www.nice.org.uk/guidance/ng28/resources
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Some search tools
STOPP.START
RCGP Indicators
PINCER
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(Un)Safety Indicators: PINCER Query Library
www.nottingham.ac.uk/primis/tools-audits/list-of-audit-tools/pincer.aspx
Query 1: Patients with a history of peptic ulcer who have been prescribed a
non-selective NSAID without co-prescription of a PPI
Query 2: Patients with a history of asthma who have been prescribed a βblocker
Query 3: Patients aged 75 years and older who have been prescribed an ACEI
or a loop diuretic long-term who have not had a computer-recorded check of
their U&E in the previous 15 months
Query 4: Women with a past medical history of venous or arterial thrombosis
who have been prescribed combined hormonal contraceptives (CHC)
Query 5: Patients receiving methotrexate for at least three months who have
not had a recorded FBC or LFT within the previous three months
Query 6: Patients receiving warfarin for at least three months who have not
had a recorded check of their INR within the previous 12 weeks
Query 7: Patients receiving lithium for at least three months who have not had
a recorded check of their lithium concentrations in the previous three months
Query 8: Patients receiving amiodarone for at least six months who have not
had a TFT within the previous six months
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Use of indicators, problematic prescribing and variation
in prescribing safety
Stocks, et al. BMJ 2015;351:h5501
• 526 practices across the UK contributing to CPRD up to April 2013.
• Anonymised data from patients >18yrs, database of 5 million.
• Analysed using indicators developed from PINCER.
• 49,927 of the 949,552 patients at risk triggered at least one
prescribing indicator – 5.26% (95% CI 5.21% to 5.30%).
• 21,501 of 182,721 – 11.8% (95% CI 11.6% to 11.9%) triggered at
least one monitoring indicator.
• The prevalence of potential prescribing hazard ranged from 0 to
10.2%, and for inadequate monitoring ranged from 10.4% to 41.9% =
substantial variation.
• Older patients and those prescribed multiple repeat medications
had significantly higher risks of triggering a prescribing indicator.
• Younger patients with fewer repeat prescriptions had significantly
higher risk of triggering a monitoring indicator.
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STOPP (Screening Tool of Older Person's Prescriptions) and
START (Screening Tool to Alert doctors to Right Treatment)
www.ucc.ie/en/misl/research/previous/stopp_start
STOPP – some CVS Examples
• Digoxin at a long-term dose > 125μg/day with impaired renal function
• Loop diuretic for dependent ankle oedema only i.e. no clinical signs of
heart failure
• Loop diuretic as first-line monotherapy for hypertension
• Thiazide diuretic with a history of gout
• Non-cardioselective beta-blocker with COPD
• Beta-blocker in combination with verapamil
• Calcium channel blockers with chronic constipation
• Aspirin at dose > 150mg day
• Aspirin with no history of coronary, cerebral or peripheral vascular
symptoms or occlusive event
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Some conclusions
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Polypharmacy: Clinical pharmacists in the team
• Support to patients: Medication reviews – medicines
optimisation
• Reviewing systems – repeat prescriptions, drug
monitoring protocols, response to hazard/warnings
• Significant event reviews, audits
• Identifying and targeting those:
• on high risk drugs
• at risk (older people, frail etc.)
• on inappropriate/unsafe drugs
• Post discharge and reconciliation reviews
• Support to care homes
• Case management
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Problematic polypharmacy, many challenges,
including….
• Time, resources, manpower – MORE doctors, nurses,
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pharmacists
Personal care and named doctors for continuity of care
Importance of formal medication review
Multidisciplinary assessment (vs. specialism)
‘One-stop shop’ reviews
Getting patient-orientated evidence of improved outcome
PDAs, Shared decision-making (and recording)
Search tools – PINCER, STOPP.START
Too many guidelines – adaptive guidelines?
Alert fatigue
Use of “order sentences” & stating what medication is for
Interfaces, and integrated care; care homes