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Problematic Polypharmacy
#PCPA16 @DrRupertPayne Problematic Polypharmacy Rupert Payne GP and Clinical Pharmacologist Senior Lecturer in Primary Health Care
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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
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Medication use is increasing
Prescribing Cost Analysis, England
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Medication use is increasing
Guthrie B, 2012
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What drives polypharmacy?
Ageing, multimorbid population Clinical guidelines and EBM Other prescribing processes
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Ageing population ONS, 2010
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Multimorbidity Barnett K, Lancet 2012
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Clinical guidelines
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Age and multimorbidity
Payne RA, Eur J Clin Pharmacol 2014
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So what?
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Inappropriate prescribing
Prevalence in over 65s Moriarty F, BMJ Open 2015
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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!
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Polypharmacy is not all bad
Payne RA, Br J Clin Pharmacol 2014
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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
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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…”
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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
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Appropriate vs. problematic
No good measures of polypharmacy Difficult to target interventions and monitor response
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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
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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
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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
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selection, procurement, delivery, prescription, dispensing, administration, review
clinical activity, audit, education, risk management, disease prevention, guideline/formulary development
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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
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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
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Which patient? Which health professional? Care setting? What point in care? Method?
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Which patient? Which health professional? Care setting? What point in care? Method?
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Beware hospitalisation
Betteridge TM, Int Med J 2011
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Monitored dose systems
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Which patient? Which health professional? Care setting? What point in care? Method?
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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
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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
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Which patient? Which health professional? Care setting? What point in care? Method?
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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
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Medication review Main medication optimisation opportunity for GPs
Repeat prescribing process cumbersome Requires dedicated time, guidance and training
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Medication review Need/indication? Open questions Tests Evidence
Adverse effects Risk reduction Simplification/switches seven steps Barnett N et al, 2015 Lewis T, 2004
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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
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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
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Deprescribing Evidence? Which patients? What approach? Effectiveness?
Safety?
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Deprescribing Patients supportive Clinicians more uncertain
Giving up on patients Disapproval of colleagues Lack of evidence or safety Inconsistent with guidelines
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Improving polypharmacy
Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems
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Improving polypharmacy
Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Training Guidance Appropriate evidence Holistic
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Improving polypharmacy
Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Identifying “at risk” patients Targeting/monitoring interventions
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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
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Improving polypharmacy
Increased resources Clinical management Quantifying polypharmacy Evidence-based interventions Improved systems Continuity of care Holistic care Coordinated care
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Problematic Polypharmacy
#PCPA16 @DrRupertPayne Problematic Polypharmacy Rupert Payne GP and Clinical Pharmacologist Senior Lecturer in Primary Health Care
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