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POLYPHARMACY


> use of two, three or more drugs is beneficial and can improve outcomes.


this is particularly true in the case of older people with multiple co- morbidities – one example being type 2 diabetes which has been complicated by coronary heart disease and hypertension. In this case, the clinician needs to consider whether each drug has been prescribed appropriately or inappropriately, both individually, and in the context of all the drugs being prescribed.


optimising prescribing in polypharmacy involves encouraging the use of appropriate drugs, in a way that the patient is willing and able to comply with, to treat the right diseases.


Identifying higher-risk polypharmacy there is potential benefit to be gained from having a simple means of identifying those individuals at particular risk of inappropriate prescribing and adverse drug events. the King’s fund 2013 report, ‘Polypharmacy and medicines optimisation – making it safe and sound’ suggested that one approach may be to focus on the following groups of ‘at risk’ patients:


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 that meets 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


• are receiving end-of-life or palliative care – where this has been explicitly recognised.


Polypharmacy in hospital Polypharmacy is, of course, not singular to primary care, with the prevalence of multiple medication use in secondary care also becoming increasingly significant.


42 - PharmacY In focUS


one american study of an acute medical service found an average increase in medicines of 2.9 from admission to discharge, while in the Italian gruppo Italiano di farmacovigilanza nell’anziano study, there was an increase in the median number of prescribed drugs from three before admission to four at discharge, driven by multi-morbidity and a number of specific clinical conditions, such as diabetes.


In an older australian population,


meanwhile, gonski et al found an average increase in the number of medications from 4.1 before admission to 4.7 at discharge.


medication errors. the most common prescribing errors were no strength or route being stated on a prescription when there was more than one option (38 per cent); an unnecessary drug being prescribed (24 per cent); the wrong dose or strength being prescribed (fourteen per cent), and not prescribing a drug (twelve per cent), when it should have been prescribed.


administration errors were probably of greater consequence and 57 residents were given the wrong drug or dose, or not given a drug (116 errors). a drug that required monitoring was prescribed to 147


‘An important challenge in the area of polypharmacy is that of working


alongside patients to empower them to


make informed choices about treatments and the burden of pills they are expected to consume. Increasingly, it is recognised that many people find their medication regiments an unpleasant chore and this can, in its own right, detract from their quality of life. If this is not managed well, medicines will not be taken as the


prescriber intends, resulting in significant and costly waste, and of course a failure to realise the anticipated benefits of treatment.’ The King’s Fund


Care homes a 2009 report by Barber et al highlighted the problems of medicines use in the United Kingdom’s care homes. the report analysed and evaluated medication errors and made some reasoned recommendations for improving care.


the researchers examined the experience of 256 residents from 55 care homes (residential, nursing and mixed), with a mean age of 85 in England. the residents were taking an average of eight medicines each – a clear indication of the complexity of their clinical conditions. Errors were identified by experienced clinical pharmacists, who interviewed patients, looked at medical records, observed care and examined the dispensing pathway.


of these 256 residents, 178 (69 per cent) had experienced one or more


residents and 27 (18 per cent) of these had an error; the most common one being the failure to carry out blood tests for monitoring purposes.


So how can medication errors be reduced? a number of studies have looked at methods to reduce the risk of harmful prescribing decisions and these are highly relevant to polypharmacy.


one of these, the PIncEr trial, was undertaken to evaluate whether a complex pharmacist-led It-based intervention was more effective than simple feedback in reducing medication error rates in general practices.


Patients from 72 general practices were assessed and, in addition to computerised feedback on patients


identified as ‘at risk’ from medication errors, the gPs met with a pharmacist to discuss the problems identified from the feedback and to agree on an action plan. the results of the trial showed that the PIncEr intervention is an effective method for reducing a range of clinically important and commonly-made medication errors in primary care.


In the King’s fund report, the authors recommended that there was a ‘need to develop systems that optimise medicines use where there is polypharmacy so that people gain maximum benefit from their medication with the least harm and waste’. this, they said, ‘may include training programmes, improved decision support for clinicians and/or patients, patient-friendly information systems, judicious use of monitored dose systems and clinical audit’.


Implications for clinical practice the report also pointed out that prescribers’ dislike of polypharmacy is not a new concept. In fact, in 1848, W newnham wrote in the Provincial medical and Surgical Journal, ‘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’.


In suggesting the optimal ‘way forward’ for polypharmacy, the authors warned that prescribers may not recognise that symptoms could be iatrogenic and may, unwittingly, prescribe new medication to counter the adverse effects of other drugs. this practice is known as ‘incremental prescribing’ or the ‘prescribing cascade’ and should, they advised, be avoided.


they also suggested that, when reviewing medications, healthcare professionals should consider whether treatment could potentially be stopped and should recognise that ‘end-of-life’ considerations apply to many chronic diseases, as well as cancer-related conditions.


consideration was also given to the patient perspective on medicine taking, with the authors recommending that ‘compromise may be needed between the view of the prescriber and the patient’s informed choice’.


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