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Polypharmacy Review

Polypharmacy Review. All Wales Therapeutics and Toxicology Centre (AWTTC) April 2014. QOF Guidance for GMS Contract 2014/2015 - Relevant indicators. Medicines Management Domain

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Polypharmacy Review

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  1. Polypharmacy Review All Wales Therapeutics and Toxicology Centre (AWTTC) April 2014

  2. QOF Guidance for GMS Contract 2014/2015- Relevant indicators Medicines Management Domain A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed 4 or more repeat medicines. 10 points GP Cluster Network Development Domain Minimising the harms of polypharmacy through an in-depth face-to-face medication review for patients aged 85 years or more receiving 6 or more medications. 15 points

  3. Six principles of medication review • Patients should have a chance to raise questions and highlight problems about their medicines • Medication reviews seek to improve or optimise impact of treatment for individual patients • Reviews are undertaken in a systematic way, by competent personnel • Any changes resulting from reviews are agreed with the patients • Reviews are documented in patients’ notes • The impacts of any changes in medication are monitored Task Force on Medicines Partnership and The National Collaborative Medicines Management Services Programme (2002) Room for review

  4. Polypharmacy ‘The concurrent use of multiple medication items by an individual.’ • Appropriate polypharmacy: defined as prescribing for a complex condition or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence. • Problematic polypharmacy: defined as the prescribing of multiple medications inappropriately, or where the intended benefit of the medication is not realised. The King’s Fund (2013) Polypharmacy and medicines optimisation

  5. Iatrogenic issues Adverse drug reactions account for: • 6.5% hospital admissions • 4% of bed occupancy Patients admitted have a median hospital stay of 8 days. Drugs most commonly implicated: Low-dose aspirin, diuretics, NSAIDs, warfarin Pirmohamed M et al. (2004). Adverse drug reactions as a cause of admission to hospital: prospective analysis of 18820 patients. BMJ 329:15-19

  6. Are you comfortable signing the repeat scripts? Ultimate responsibility for every script lies with whoever signs it.

  7. How do you tackle a polypharmacy review ?

  8. STOPP START criteria STOPP(Screening Tool of Older Person's Prescriptions) criteria identifies most commonly prescribed potentially inappropriate medications and START (Screening Tool to Alert doctors to Right Treatment). Gallagher P et al. (2008). STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J ClinPharmacolTher. 46:72-83.

  9. STOPP START STOPP e.g. • PPI full therapeutic dose • Aspirin • Duplicate medicines • Benzodiazepines and 1+ fall in last 3 months • Long-term, long-acting benzodiazepines • NSAID long term for mild joint pain osteoarthritis • Long-term opiates or neuroleptics in patients with recurrent falls (1+ fall in last 3 months) Gallagher P et al. (2008). STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J ClinPharmacolTher. 46:72-83.

  10. Resources for STOPP START criteria National Prescribing Indicators 2014–2015: Supporting Information for Prescribers

  11. Resources for STOPP START criteria(Cont.) • AWTTC (2013) PPI and Dyspepsia Resource Pack • Welsh Medicines Partnership (2011) Educational Pack: Material to support appropriate prescribing of hypnotics and anxiolytics across Wales • AWMSG (2010) CEPP National Audit - Towards Appropriate Non-Steroidal Anti-Inflammatory Drug (NSAID) Prescribing

  12. Polypharmacy – Guidance for Prescribing in Frail Adults Provides clinicians with a structured process of rationalising patients’ medication, in particular for frail and elderly patients. Includes: • Summary charts • Medicine-specific advice by BNF chapter Adapted from Abertawe Bro Morgannwg University and Hywel Dda Health Board documents, originally adapted from NHS Highland, and from resources by Emyr Jones, Aneurin Bevan University Health Board.

  13. Polypharmacy – Guidance forPrescribing in Frail Adults(Cont.) SUMMARISES KEY CONSIDERATIONS FOR: • Drug review process • High-risk medications/combinations • System-based factors (CV, GI etc) • Patients with dementia • Anticholinergic load/combinations • Frailty • Shortened life expectancy • Practical guide to stopping medication including transdermal opioids, antidepressants, benzodiazepines • Number needed to treat for specific medicines

  14. ‘NO TEARS’ • Need/indication • Open questions • Tests/monitoring • Evidence/guidelines • Adverse effects • Risk reduction/prevention • Simplification/switches Lewis, T (2004) ‘Using the NO TEARS tool for medication review’ BMJ 329: 434 WeMeReC (2005) Bulletin: Medication Review for the 10 minute consultation

  15. NO TEARS brief exampleMedicine Last collected • Calcium/Vit D3 bd 56 2 months ago • Betnovate30 g last month • Co-codamol 8/500 mg 2qds prn 200 last month • Amlodipine 5 mg od 28 last month • Gliclazide80 mg bd 56 last month • Metformin 500 mg bd 56 last month • Tramadol 50 mg 2qds prn 100 last month • Accu-Chek 2 months ago • Omeprazole 20 mg od 28 last month • Glucosamine od 28 last month

  16. NO TEARS brief example Need and Open • Patient’s view of regular medicines? • “What do you take each day?” • “I realise a lot of people don’t take all their tablets. Do you have any you don’t like?” • Calcium taken? PPI still needed? Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28; co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56; metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100; Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28

  17. NO TEARS brief example Tests Diabetes/hypertension monitoring, osteoarthritis functional impact Evidence Diabetes - consistent with current guidance Osteoarthritis - tramadol? Stop glucosamine Dermatology - steroid on repeat, no emollient Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28; co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56; metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100; Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28

  18. NO TEARS brief example Adverse Events steroid on repeat Risks co-codamol + tramadol Simplification/synchronisation/switch/stop stop glucosamine, switch glucose testing strips? Calcium/Vit D3 bd 56; Betnovate 30 g; amlodipine 5 mg od 28; co-codamol 8/500 mg 2qds prn 200; gliclazide 80 mg bd 56 metformin 500 mg bd 56; tramadol 50 mg 2qds prn 100; Accu-Chek; omeprazole 20 mg od 28; glucosamine od 28

  19. Combine with a basic approach? • STOPPED • SORTED • SPECIAL

  20. Stopped, Sorted, Special Stopped • The obvious ones • left out when patient lists meds taken • not collected/expired • infrequent requests/low % use • short course completed • shouldn’t be on repeat • hospital letters stated stop • condition resolved

  21. Stopped, Sorted, Special Has been assessed and monitored within the last 12 months, e.g. - Chronic disease clinic • Hospital review - and no outstanding concerns

  22. Stopped, Sorted, Special - Priorities Consider medicines recently highlighted: • High-risk medicines • Practice priorities • AWMSG National Prescribing Indicators • Local comparators • MHRA alerts • NICE

  23. Six principles of medication review • Patients should have a chance to raise questions and highlight problems about their medicines • Medication reviews seek to improve or optimise impact of treatment for individual patients • Reviews are undertaken in a systematic way, by competent personnel • Any changes resulting from reviews are agreed with the patients • Reviews are documented in patients’ notes • The impacts of any changes in medication are monitored Task Force on Medicines Partnership and The National Collaborative Medicines Management Services Programme (2002) Room for review

  24. Additional Resources • AWMSG CEPP National Audit: Repeat Prescribing (Practice systems) • WeMeReC Bulletin: Prescribing for Older People (2011)

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