Seven Steps To Managing Polypharmacy - Clinical Pharmacy

S P Specialist Pharmacy Service S Medicines Use and Safety Seven steps to managing polypharmacy: ?image 8211 Specialist Pharmacy Service Winner: RPS Pharmaceutical Care Award 2013 Finalist: HSJ Patient safety award in primary care 2013; Winner: UKCPA/Guild Conference Best Poster award 2013 Winner: UKCPA Pain award 2012; Winner: UKCPA Respiratory award 2012

S P S Medicines Use and Safety Introduction Medicines are the most common intervention to improve health and concerns about the risks of polypharmacy in primary and secondary care are growing. Published evidence associates polypharmacy with increased adverse drug events, hospital admissions, increased health care costs and nonadherence. This has led to the suggestion that “Polypharmacy itself should be conceptually perceived as a “disease” with potentially more serious complications than those of the diseases these different drugs have been prescribed for”1 There are number of terms which have come into use over recent years to describe multiple medicines use: Polypharmacy is a term that refers to either the prescribing of or taking many medicines. For many years it referred to the prescription or use of more than a certain number of medicines, at least four or five or more medicines per day (see A2). More recently it has been used in the context of prescribing or taking more medicines that are clinically required, as the number of medicines taken was of limited clinical value in interpreting individual potential problems. The Kings fund2 divides the definition into “appropriate” and “problematic” polypharmacy which is a helpful distinction in practice and other terms are also in use: Appropriate polypharmacy ”Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence.” Problematic polypharmacy “the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not realised.” Oligopharmacy seeks to promote the deliberate avoidance of polypharmacy, which if considered in terms of numbers of medicines, is the prescribing of less than 5 prescription drugs daily.3 Deprescribing is the complex process required for the safe and effective cessation (withdrawal) of inappropriate medication, recognising that much of the evidence to support stopping medicines is empirical and based on the patient’s physical functioning, co-morbidities, preferences and lifestyle. Hyperpolypharmacy is a new term referring to the prescribing of ten or more medicines and the phrase has come into use to distinguish it from polypharmacy, which is increasingly common.4 Prescribers caring for patients with multiple morbidities are further challenged by the absence of evidence based national guidance, incorporating the patient perspective, around reducing and stopping medication. The central challenge of optimal management of polypharmacy is creating a balance between evidence based medication review and patient preferences in managing their health and communicating this effectively between health care providers. This process has been created to assist with medication review and decisions around deprescribing in the context of polypharmacy and aims to address polypharmacy as part of overall medicines optimisation strategies. It can be used in successive consultations to address one or a small number of polypharmacy issues at a time. While it likely to be most applicable in community settings, the principles can be applied to all patient care settings. Developed by Nina Barnett and Lelly Oboh, Consultant Pharmacists working with Older People, Medicines Use and Safety Team, NHS Specialist Pharmacy service, and Katie Smith, Regional Medicines Information Director, East Anglia Medicines Information Service, it is based on published evidence and current practice and has been reviewed by clinicians who work directly with patients. A list of key reference documents with content summary is provided following the process together with references for further reading. 1 Garfinkel D and Mangin D 2010. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults Arch Intern Med Vol 170 (no. 18) p 1648 acy-and-medicines-optimisation O’Mahoney D and O’Connor M N, Pharmacotherapy at the end-of-life Age and Ageing 2011; 0: 1–4 doi: 10.1093/ageing/afr059 4 Gnjidic, Danijela, Le Couteur, David G, Pearson, Sallie-Anne, McLachlan, Andrew J, Viney, Rosalie, Hilmer, Sarah, Blyth Fiona M N, Joshy, Grace and Banks, Emily. High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level. BMC Public Health 2013, 13:115 http://www.biomedcentral.com/1471-2458/13/115 2 3 Polypharmacy and medication review - Seven Steps Vs2- Jan 2015 (NB) 2

S P S Medicines Use and Safety Seven steps to managing polypharmacy in practice Nina Barnett Lelly Oboh & Katie Smith, NHS Specialist Pharmacy Service 2015 Polypharmacy and medication review - Seven Steps Vs2- Jan 2015 (NB) 3

S P S Medicines Use and Safety 1. Assess patient: Find out what medicines matter to the patient and/or carer and what they want to discuss or review Ask about practical aspects of medicines taking e.g “how do the medicines fit in to your typical day?” Obtain a full medical, medication history including functional history5 –with the patient and/or carer Use tools to estimate frailty6, life expectancy (eg NHS Hhighland tool)7 & predict trajectory decline 2. Define overall patient goals Share and discuss your suggestions for medication review focus with the patient. Medication review is best undertaken focussing on a small number of drugs rather than the complete list in one session. Agree shared desired outcomes for overall health with the patient/carer ensuring that overall medicines optimisation goals are congruent Focus on medicine-related benefit they want to derive Agree priority areas of medication focus for this consultation 3. Identify inappropriate drugs from an accurate list of medication using an evidence based tool (see tools step 4) Undertake medicines reconciliation (see also NICE guidance 8) and review – What is the patient ACTUALLY taking compared to what is prescribed? – What non prescribed medicines does the patient take (over the counter, herbal etc.) – How does the patient manage their medicines? i.e. are they able to take each drug and does it fit into their daily activities? Consider: Which conditions are active, inactive, time bound, resolved? What is bothering the patient most? – link this to goals, which may need to be revisited at this time. What perceived and actual harms or benefits are they experiencing for each drug in relation to their condition. Is there a valid indication for each drug? Are symptoms vague? subjective versus objective? Identify and manage new symptoms/conditions. Note these may be linked to starting a new medicine or relate to medicines started to treat a side effect i.e.prescribing cascade. It is helpful to begin with open questions and increase focus with closed questions. 5 s/approach to the geriatric patient/evaluation of the elderly patient.html and http://www.aafp.org/afp/2011/0101/p48.html 02/safe-comp-care.pdf 7 0prescribing%20in%20frail%20adults.pdf 8 mzybqg5m 6 Polypharmacy and medication review - Seven Steps Vs2- Jan 2015 (NB) 4

S P S Medicines Use and Safety 4. Assess each drug for specific risks vs benefits in context (you may do this at consecutive appointments taking one condition at a time, led by the patient’s need) Working with the patient/carer to explore general risks & benefits for each drug: consider each symptom and each drug in terms of beneficial and potential adverse effects – consider drugs as “guilty until proved innocent” and conditions as drug related until proven otherwise then: Apply tools to identify potentially inappropriate medicines e.g. STOPP/START tool - NHS Cumbria toolkit9, Beers Criteria (updated 2012)10, Drug effectiveness summary (NHS Highland tool)11, MAI tool 12, NO TEARS 13 Review pathology results in relation to medicines including monitoring 14 e.g. Renal function in relation to NSAID or ACE inhibitor use, Liver function in relation to statin use. Use your clinical judgement and experience, in relation specific risks & benefits for each drug in the context of individual patient, and consider: – Does each drug have a “matching” indication, is the indication still valid? – Does the drug produce limited benefit for that indication15? – What is the evidence for benefit in older people and is this outweighed by unfavourable side effects? – Is the overall regimen tailored to the patient’s circumstances, morbidities, preferences, overall clinical and social situation and ability to adhere to agreed regimen Use prognostic tools for shortened life expectancy (NHS Highland tool)16 and clinical judgement – Does each drug fit in or conflict with overall goal? – Will patient live long enough to benefit? Discuss options with the patient and agree a way forward (including explaining referral to prescriber where appropriate) 9 esManagement/Guidelines/StopstartToolkit2011.pdf beers/2012BeersCriteria JAGS.pdf 11 0prescribing%20in%20frail%20adult s.pdf 12 armacy.pdf 13 13%5D.pdf 14 2014.pdf 15 uide2011.pdf 16 0prescribing%20in%20frail%20adults.pdf 10 Polypharmacy and medication review - Seven Steps Vs2- Jan 2015 (NB) 5

S P S Medicines Use and Safety 5. Agree to stop or reduce dose Where possible, arrange a face to face meeting with the prescriber if you are not the prescriber yourself Prepare a range of options for each drug – discuss with GP/prescriber as appropriate Present in a simple format – by drug (ICARUS grid)17 – By group of drugs to treat a condition – Be clear what action to take for each drug Review and agree plan with patient Withdraw slowly Follow up with written summary highlighting rationale, agreed action for each drug change and monitoring, with a copy to the patient. 6. Communicate with GP/prescriber/community pharmacist as appropriate Produce written summary highlighting rationale, agreed action for each drug change and monitoring Send to prescriber and patient and/or carer Inform community pharmacist and any other health or social care professional involved in medicines related activity as appropriate 7. Monitor, review and adjust regularly 17 18 Talk to the patient about monitoring they can expect 18 Agree patient led monitoring as appropriate Be clear with patient and professionals responsible about what monitoring is needed and ensure its in place – Look out for toxicity, benefits – Look out for non-specific adverse effects e.g. worsening of geriatric syndromes like falls, dementia, confusion, urinary incontinence Agree a specific date to review these changes Discuss next steps OR review on an ongoing basis (may be a next appointment) Inform others who need to know about changes made and/or act on them (with patient’s consent as appropriate) Ensure changes are clear especially if no prescription will follow. ents/oct11/ICARUS%20Grid.pdf 2014.pdf Polypharmacy and medication review - Seven Steps Vs2- Jan 2015 (NB) 6