Problematic Polypharmacy #PCPA16 @DrRupertPayne r.payne@bristol.ac.uk Problematic Polypharmacy Rupert Payne GP and Clinical Pharmacologist Senior Lecturer in Primary Health Care

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 No single agreed definition, OED definition is probably incorrect although does have negative connotations Google Ngrams, Oxford English Dictionary

Medication use is increasing Prescribing Cost Analysis, England

Medication use is increasing Guthrie B, 2012

What drives polypharmacy? Ageing, multimorbid population Clinical guidelines and EBM Other prescribing processes

Ageing population ONS, 2010

Multimorbidity Barnett K, Lancet 2012

Clinical guidelines

Age and multimorbidity Payne RA, Eur J Clin Pharmacol 2014

So what?

Inappropriate prescribing Prevalence in over 65s Moriarty F, BMJ Open 2015

Black dot interactions Medication errors 16% increase per drug Black dot interactions >50% 10+ drugs Medication adherence half 5+ drugs QoL Quality of Life ↓↓ Waste!

Polypharmacy is not all bad Payne RA, Br J Clin Pharmacol 2014

Defining polypharmacy Specific numeric thresholds Widely used Simple and easy to implement “Four or more” Which drugs? Short vs. long term? OTC? Polypharmacy is a continuum Ignores appropriateness

King’s Fund definition Appropriate polypharmacy “…medicines use has been optimised and … prescribed according to best evidence. The overall intent … to maintain good quality of life, improve longevity and minimise harm…”

King’s Fund definition Problematic polypharmacy “…prescribe inappropriately … or where intended benefit … not realised … not evidence-based … risk of harm from treatment is likely to outweigh benefit … one or more [other issues]” Other problems: Hazardous combination, unacceptable treatment burden, clinically useful adherence cannot be achieved, prescribing cascade

Appropriate vs. problematic No good measures of polypharmacy Difficult to target interventions and monitor response

Identifying polypharmacy Tools for identifying inappropriate prescribing Range of criteria available Explicit “specific” criteria (e.g. Beers’, STOPP, RCGP) Implicit “generic” criteria (e.g. MAI) Not specifically designed for polypharmacy Most are easily implemented in clinical IT systems Restricted to a relative small, finite problem list

Identifying 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 NICE MM guideline supports this

Identifying polypharmacy Using frailty to target a “tailored approach” to managing multimorbidity gait speed, timed “up and go” self-reported health status PRISMA-7 NICE tailored approach for MM: improving quality of life by reducing treatment burden, adverse events, and unplanned care the person’s individual needs, preferences for treatments, health priorities, and lifestyle and goals how the person’s health conditions and their treatments interact and how this affects quality of life the benefits and risks of following recommendations from guidance on single health conditions improving coordination of care across services

selection, procurement, delivery, prescription, dispensing, administration, review clinical activity, audit, education, risk management, disease prevention, guideline/formulary development

Optimising polypharmacy Optimise therapy Improve outcomes Reduce Errors Inappropriate prescribing Waste Burden of treatment Not cutting costs Optimise therapy Improve clinical outcomes and quality of life Reduce Errors Unnecessary/inappropriate prescribing Waste Burden of treatment Not cutting costs

Polypharmacy interventions Patterson Cochrane systematic review 2012 10 studies in older patients Multi-faceted complex interventions Computer decision support Pharmacy-led Concludes questionable evidence of benefit

Which patient? Which health professional? Care setting? What point in care? Method?

Which patient? Which health professional? Care setting? What point in care? Method?

Beware hospitalisation Betteridge TM, Int Med J 2011

Monitored dose systems

Which patient? Which health professional? Care setting? What point in care? Method?

Pharmacist interventions work! PINCER Trial Complex pharmacist-led intervention Computerised feedback Face-to-face meetings with GP Educational outreach, root-cause analysis Significant reduction in medication errors Did not focus on polypharmacy Pharmacy interventions work

Working together One HCP is not the solution: needs multidisciplinary working and better communication – esp GPs/pharmacists GPs good at managing complex medical problems, Pharmacists good at managing medications Lack of communication between GPs and pharmacists, unactioned MURs by GPs GP forward view: opportunity for pharmacists based in GP surgeries Culture shift – patients don’t always like/heed pharmacist advice, especially if conflicts with GPs

Which patient? Which health professional? Care setting? What point in care? Method?

Systems/processes Continuity of care Communication Repeat prescribing Lack of continuity of care, named GPs Lack of communication between GPs and pharmacists, unactioned MURs by GPs

Medication review Main medication optimisation opportunity for GPs Repeat prescribing process cumbersome Requires dedicated time, guidance and training

Medication review Need/indication? Open questions Tests Evidence Adverse effects Risk reduction Simplification/switches seven steps Barnett N et al, 2015 Lewis T, 2004

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

Patient centred Deprescribing Review of medications and indications Consideration of harms Assessment of eligibility for discontinuation Prioritisation of medications Implementation of a stopping plan with appropriate monitoring Scott IA, JAMA Intern Med 2015

Deprescribing Evidence? Which patients? What approach? Effectiveness? Safety?

Deprescribing Patients supportive Clinicians more uncertain Giving up on patients Disapproval of colleagues Lack of evidence or safety Inconsistent with guidelines

Improving polypharmacy Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems

Improving polypharmacy Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Training Guidance Appropriate evidence Holistic

Improving polypharmacy Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Identifying “at risk” patients Targeting/monitoring interventions

Improving polypharmacy Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Proactive and reactive Better IT Patient centred Pharmacists and GPs working together GPs taking more responsibility Empower clinicians

Improving polypharmacy Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Continuity of care Holistic care Coordinated care

Problematic Polypharmacy #PCPA16 @DrRupertPayne r.payne@bristol.ac.uk Problematic Polypharmacy Rupert Payne GP and Clinical Pharmacologist Senior Lecturer in Primary Health Care