1. POLYPHARMACY AND MEDICINES OPTIMISATION Professor Tony Avery, University of Nottingham, in collaboration with Dr Martin Duerden Dr Rupert Payne 1

2. 2 “We dislike polypharmacy as much as it is possible, and we would never exhibit a remedy of any kind unless we had a scientific reason for so doing and unless we were prepared to defend our method of treatment.....” Newnham W. Remarks on the present aspect of medicine. Prov Med Surg J 1848;p281-285 Published 31 st May 1848. (The Provincial Medical and Surgical Journal was the forerunner to the British Medical Journal)

3. Scope of presentation Defining and measuring polypharmacy, and the concept of deprescribing Evidence-based polypharmacy and how to evaluate evidence to judge whether medicines continue to provide net benefit The key issues in optimising prescribing in older people Key recommendations for service redesign and research needed to improve the management of patients require medicines for multiple conditions 3

4. Issues with polypharmacy Polypharmacy is an expression that has been used for many years in medicine; it is generally understood as referring to the concurrent use of multiple medication items in one individual. In the past polypharmacy has been frowned upon and considered something to be avoided. It is now accepted that in many circumstances polypharmacy can be therapeutically beneficial. Polypharmacy may be harmful as it will increase the risk of drug interactions and adverse drug reactions, together with impairing medication adherence and quality-of-life as regimens may be too complex or unacceptable to patients. 4

5. Definitions 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. 5

6. Definitions Problematic polypharmacy is prescribing of multiple medications inappropriately, or where the intended benefit of the medication is not realised. The reasons for this may be that the treatments are not evidence-based, or the risk of harm from treatments is likely to outweigh benefit, or 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’ is unacceptable to the patient The demands of medicine taking means that it is not possible to achieve clinically useful adherence (reducing the ‘pill taking 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 6

7. Higher risk polypharmacy All patients with ten or more regular medicines (for example, those medicines taken every day or every week) Patients receiving between four and nine regular medicines who also: Have at least one prescribing issue meeting criteria for potentially inappropriate prescribing Have evidence of being at risk of a well-recognised potential drug- drug interaction or have a clinical contraindication Have evidence from clinical records of difficulties with medicine taking, including problems with adherence Have no or only one major diagnosis recorded in the clinical record (it might be expected that large numbers of medicines are unlikely to be justified in patients without multiple clinical conditions) Are receiving end of life or palliative care (where this has been explicitly recognised) 7

8. The concept of de-prescribing The current model of prescribing is based very much around adding drugs as patients develop more conditions Given the risks of adverse drug events (especially with the 'therapeutic cascade‘); problems with adherence, and limitations on effectiveness, it is important to consider whether to discontinue some medicines in some patients The concept of de-prescribing involves carefully assessing patients’ medicines and (with patient and/or carer consent) withdrawing those that may be harmful or no longer providing benefits More on this later… 8

9. Epidemiology of polypharmacy Demographics Increases in multimorbidity with age Comorbidity of common conditions Prevalence of polypharmacy 9

10. Estimated and projected age structure of the United Kingdom population, mid-2010 and mid-2035 http://www.ons.gov.uk/ons/dcp171778_235886.pdf http://www.ons.gov.uk/ons/dcp171778_235886.pdf 10

11. Number of Chronic Disorders by Age Group Barnett K et al. Lancet 2012; 380: 37-43. 11

12. Comorbidity of 10 common conditions among UK primary care patients Guthrie B et al. BMJ 2012;345:e6341 12

13. Prevalence of multiple medicines prescribing in a Scottish primary care population [Payne R, unpublished data] 13

14. Evaluating evidence to judge whether medicines continue to provide net benefit? Evidence-base for polypharmacy is poor Nevertheless, prescribers are faced with difficult decisions when often all we have to go on is evidence-based guidelines for single conditions In many cases, however, it does seem appropriate to prescribe multiple medications based on existing 'single condition' evidence provided that: Benefits are likely to outweigh harms Patient is willing and able to take the medication Therapeutic cascade is avoided if at all possible There are, however, circumstances where the evidence is not strong enough to justify continued treatment 14

15. Questions to ask when considering stopping medication (WeMeReC 2010) Is the drug still needed? Has the condition changed? Can the patient continue to benefit? Has the evidence changed? Have the guidelines changed? Is the drug being used to treat an iatrogenic problem? Are there ethical issues about withholding care? Would discontinuation cause problems? Some therapies should not be stopped abruptly following long-term use. What does the patient/carer think? 15

16. Changing priorities, towards the end of life As patients with multimorbidity age and become frail, and preventative treatments become less meaningful, prescribers should consider when it is appropriate to broach the subject of scaling back or stopping treatment This then needs a discussion with the patient and caregivers about revision of treatments and limitations on investigations Prescribers need to decide in what particular order to taper or eliminate treatments NHS Scotland Polypharmacy Guidance, 2012, is helpful here http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%2 0full%20guidance%20v2.pdf http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%2 0full%20guidance%20v2.pdf 16

17. NHS Scotland Polypharmacy Guidance Consider what is the outcome being avoided? Consider using NNTs per annum to inform decisions of withdrawal of medication, e.g. NNTs of >50/year for: Statins post MI (to prevent another major coronary event) Statins post stroke (to prevent another stroke) Metformin in overweight diabetic (to prevent MI, diabetes event or death) BP <140 systolic in diabetes (to prevent stroke, diabetes event or death) Alendronate + calcium/vit D to prevent further fracture Consider where NNT>NNH, e.g. Sedative hypnotics in older people with insomnia 17

18. Key issues in optimising prescribing in older people Thorough medication review is extremely important How do we achieve this? Taking account of drugs that are poorly tolerated Antipsychotics, tricyclic antidepressants, benzodiazepines, opioids and anticholinergics Taking account of drugs that may still be beneficial Many cardiovascular medicines Monitored dose systems May help with adherence, may improve some outcomes, but may also cause problems! Medicines reconciliation at hospital discharge Care home settings 18

19. Medication review Thorough medication review is probably the most important method for identifying and correcting problems with polypharmacy Needs a review of each medicine, and the medication regime as a whole, in terms of: Right drug? Appropriate for the condition with no contraindications or hazardous drug interactions Right dose? Right instructions? Right monitoring? Right for the particular patient? Can they cope with the medication burden? Do they want to cope with medication burden? 19

20. Polypharmacy in care home settings The following may help: A lead GP for each home Pharmacist medication review One person, (ideally a pharmacist) having overall responsibility for medicines use in the care home Regular review of the use and accuracy of medication administration records (lack of protocols and adequate staff training is an issue) Considering the timing of medication administration to ease busy morning drug rounds, which can often be interrupted 20

21. DON’T FORGET WASTE 21

22. Key recommendations for service redesign Current model is not optimal Major investment in clinical pharmacy is likely to be helpful Detailed medication review for patients at greatest risk, and liaison with prescribers for medicines optimisation Care home prescribing particularly important PINCER-trial approach to identifying and managing patients with hazardous prescribing and inadequate blood test monitoring Having more pharmacists working as independent prescribers in primary care, particularly if this is well-coordinated Improving safety systems Consider the development of specialist GPs, and/or investment in community geriatricians 22

23. Key recommendations for research Need much better evidence for the benefits and risks of polypharmacy in patients with multimorbidity More trials would be ideal, but consider use of clinical database studies More evidence needed on the views of older people concerning polypharmacy and NNT/NNH Is prolonging life expectancy the most important issue to all the people? More evidence needed on the benefits of different models of medicines optimisation for older people Trials needed to assess the benefits and risks of judicious de-prescribing in older people 23

24. Summary Polypharmacy is becoming increasingly common, particularly in older people with multimorbidity It is important to take account of current evidence when considering medicines optimisation in older people Nevertheless, further evidence would be helpful, particularly in terms of the benefits and risks of de- prescribing We know enough already, however, to recognise that clinical pharmacists have an extremely important role in medicines optimisation in older people, and that services need to be redesigned to take account of this 24

25. How can we stop good doctors from making bad mistakes? Thank you, for listening!