1. Polypharmacy Review T. Lewis GP

2. 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 reviewRoom for review

3. 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 optimisationPolypharmacy and medicines optimisation

4. 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

5. Are you comfortable signing the repeat scripts? Ultimate responsibility for every script lies with whoever signs it.

6. How do you tackle a polypharmacy review ? T Lewis 2014

7. 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.

8. 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.

9. Resources for STOPP START criteria National Prescribing Indicators 2015–2016: Supporting Information for Prescribers

10. 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.

11. Polypharmacy – Guidance for Prescribing 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

12. ‘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: 434Using the NO TEARS tool for medication review WeMeReC (2005) Bulletin: Medication Review for the 10 minute consultationBulletin: Medication Review for the 10 minute consultation

13. NO TEARS brief example Medicine Last collected Calcium/Vit D3 bd 562 months ago Betnovate 30 g last month Co-codamol 8/500 mg 2qds prn 200last month Amlodipine 5 mg od 28 last month Gliclazide 80 mg bd 56last month Metformin 500 mg bd 56last month Tramadol 50 mg 2qds prn 100 last month Accu-Chek2 months ago Omeprazole 20 mg od 28last month Glucosamine od 28last month TL 2014

14. NO TEARS brief example 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? 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 T.L. 2014

15. NO TEARS brief example Tests Diabetes/hypertension monitoring, osteoarthritis functional impact Evidence Diabetes - consistent with current guidance Osteoarthritis - tramadol? Stop glucosamine Dermatology - steroid on repeat, no emollient 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 T.L. 2014

16. NO TEARS brief example Adverse Events steroid on repeat Risks co-codamol + tramadol Simplification/synchronisation/switch/stop stop glucosamine, switch glucose testing strips? 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 T.L. 2014

17. Combine with a basic approach? STOP SORTED SPECIAL T. Lewis 2014

18. 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

19. 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

20. 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

21. 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 reviewRoom for review