Polypharmacy and de-prescribing

Question 1

Polypharmacy

Answer 1

Simultaneous use of multiple medicines by a patient for their conditions. >5 medications

Question 2

Deprescribing

Answer 2

Stop/swap medication OR reducing dose after review

Aim to reduce .inappropriate polypharmacy

Shared decision making to improve patient quality of life

Question 3

Results of polypharmacy

Answer 3

Increased mortality, risk of falls, more ADRs, increased length hospital stay, economic cost, patient safety incidents

Question 4

Appropriate Polypharmacy

Answer 4

optimum minimum number of medications for complex patient

Question 5

Problematic polypharmacy

Answer 5

unbalanced / inappropriate use of multiple medications increasing risk of drug-drug interactions and ADRs

Question 6

How to reduce ADRs?

Answer 6

1. Follow guidelines / evidence to use most appropriate drug
2. Consider co-morbidities
3. Ensure shared patient care with other HCPs
4. Awareness of polypharmacy
5. Medication optimisation and review
6. Patient involvement and education, improve adherence

Question 7

Example of polypharmacy

Answer 7

chronic pain –> depression Rx morphine + benzodiazepine = respiratory depression

oxycodone –> consitpation –> senna –> electrolyte imbalance / dehydration

NSAID –> increase BP –> amlodipine –> hypotension

Question 8

Causes of polypharmacy in opioid patients

Answer 8

multimorbidities (CNS)
multi-prescribers (opioid tourism)
Dependence / addiction

Question 9

Multimorbidity

Answer 9

> 2 long-term health conditions (physical, mental, learning disability, misuse, chronic pain, frailty, hearing loss)

RFs: age, economic, physical/mental

Question 10

Relative Contraindication

Answer 10

Use with caution
Benefit vs. Risk

Question 11

Absolute Contraindication

Answer 11

AVOID!
Life-threatening
Find alternative

Question 12

Factors affecting contra-indications

Answer 12

Age
Gender
Previous ADRs
Allergy
Multi-drugs (interactions)
Hepatic impairment
Renal impairment
HF
Drug-disease interactions
Altered pharmacokinetics

Question 13

PIMS

Answer 13

Potential Inappropriate Medications

Guidelines

Question 14

Medication Review and Tools

Answer 14

Beets Criteria
STOP/START
ImPE project
STOP-IT: high risk polypharmacy, stop/swap dependent on admission reason

Question 15

Example of STOP/SWAP

Answer 15

Metabolic disturbance from diuretics, ACEi, ARBs, NSAIDs, SSRIs

Falls from Benzo’s, Z-drugs, opioids

Question 16

Patient Centred Care

Answer 16

assess pt, define pt goals, identify meds of concern, agree priorities for review, adgree to stop/reduce dose, communicate actions with all relevant people

Question 17

Medicines optimisation RPS 2013

Answer 17

patient-focused
holistic
partnership with patient
MDT
monitor and review
Right patient get the right medicine at the
Patient takes ownership (take medicines correctly, avoid taking unnecessary medicines, reduce wastage of medicines and improve medicines safety)

Question 18

x4 principles of medication optimisation

Answer 18

RPS guidelines 2013
1. Aim to understand patient experience - open Qs, engagement, might change over time, improves pt confidence
2. Evidence based choice of medication - NICE guidelines, regular review, optimal pt outcome,
3. Ensure medicine use safe - ADRs, interactions, safe processes and systems, effective communication MTD, avoid harm, reduced hospital admissions, MRHA reporting
4. Make medicine optimisation part of routine practice - how to get best out of medication, signposting, interprofessional, reduce waste