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1 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 6 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 7 Multimorbidity: Number of chronic disorders by age group Barnett K et al. Lancet 2012; 380: 37-43. 8 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 11 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… 12 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. 13 14 Why is it so problematic? Guidelines everywhere… 2008 • • • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • • • 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 16 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 18 19 So what can we do? 21 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.’ 22 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 24 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 • • • • 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 28 General issues • Identify the concerns, preferences and • • • • • • 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 30 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 32 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 33 NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources 34 Some search tools STOPP.START RCGP Indicators PINCER 35 (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 36 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. 37 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 38 Some conclusions 39 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 40 Problematic polypharmacy, many challenges, including…. • Time, resources, manpower – MORE doctors, nurses, • • • • • • • • • • • 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