MYCPD PolyPharmacy – A cocktail of medicines

We have been carrying out an extensive research on the topic of Polypharmacy. We hope to explore solutions and also to give an insight into my views. Polypharmacy is a key problem of which patients experience and places a great deal of burden on the NHS.

Polypharmacy has been widely defined simply as the prescription of multiple medications for an individual. This can be appropriate or inappropriate depending on a variety of factors and the individual.

 

Causes of Polypharmacy

  1. Ageing Population – Standards of Healthcare have advanced, medications and technology are keeping people alive for longer. Thus we have an ageing population, therefore increased Co-morbidities (more medication).
  2. Evidence Based Practice – The healthcare practice in the UK, has to its credit become more evidence based. This has been due to various stimulus from organisations such as NICE. Which have advocated the prescribing of medications with the aim of preventing or managing conditions. Thus prescribers feel obliged to prescribe mainly for preventative purpose as advised by the guidelines. However, the guidelines may not focus on patients with complex co-morbidities.
  3. Lack of communication – This is something which spans across the NHS. For example, lack of access to patient records in Community Pharmacies. How do we expect Community Pharmacist to successfully monitor patient in the Community when they are uncertain as to why they are taking the medication. Thus it is difficult for a Community Pharmacist to identify when a medication is not needed by a patient.
  4. Lack of Factorial designs in clinical trials – Majority of clinical trials focus on one medication (intervention) been taking at a time; the trials evaluate the experimental arm and compares results with those from the placebo arm. Thus it provides little information on concomitant use of multiple medication for treatment of a condition or co-morbidities.
  5. Diagnostic Purity Bias – A common occurrence in sample population; often excludes co-morbidity. Thus the sample eludes the complexity of the true population.

When is PolyPharmacy appropriate?

  • Evidence based practice – When Polypharmacy is inline with evidence based practice (NICE, SIGN and appropriate guidelines), but we should still go further; take a pragmatic approach and evaluate the plethora of medicines. It should not be acceptable to simply prescribe and assume it is fine/safe because it iis inline with NICE. The notion “not one size fits all” should be paramount.
  • Focused and Optimised – when the domino effect (see below) is avoided. And the treatment of a patient is focused and not divergent; using medicines to treat the side effects of other drugs. Unless this is unavoidable.
  • Evaluation – When there are measurable benefits of taking multiple medication.
  • Consultation – Polypharmacy should only be appropriate if patients (mentally capable) are aware of the medications they are taking and have agreed to this. There is nothing worse than dispensing a medication for a patient and informing the patient of how to take the medication, only to find out that they don’t even know what its for!

When is PolyPharmacy inappropriate?

  • Evidence based practice – when Polypharmacy is not inline with evidence based practice. Alternatively, when it is inline with evidence based practice but does not take a pragmatic approach.
  • Risk / Benefit – A consideration should be taken to continually review patients medications to access whether the risk out weigh the benefit (i.e. Side effects).
  • Domino effect (Iatrogenic) – Often times, a medication can be prescribed which causes a side effect. Then a further medication is prescribed to treat that side effect. I think we should evaluate prescribing and ask have we lost sight of the initial condition we are trying to treat.
  • Patient Objections – When the patient is not happy or objects to Polypharmacy. The Gold standard of any treatment involves an agreement with a patient. A discussion should occur to rectify any issues to ensure adherence.

What can be done?

In order to have a realistic chance of tackling Polypharmacy, it is important to ensure that not only are Healthcare Practitioners involved in this challenge but that the following are included:

  1. Social Services – Visits to elderly patient should report concerns of excessive medications, especially medications of which have been found to be untaken dating over a month.
  2. Carers/Relatives – If you feel medication is being hoarded.it is best to discuss your concerns with the patient and consider reporting this to their HCP.
  3. The Pharmaceutical Industry – Platforms should be in place to facilitate better information transfer between the Pharmaceutical industry and HCP’s. For example, reporting of Adverse events (AEs), concomitant use of medication by HCP or the patient. This information helps to build knowledge of the Safety Profile of the medication. It also allows for investigations into AEs to occur.
  4. Organisations such as NICE or SIGN – More guidance/focus relating to concomitant conditions and drug use in elderly.

Development of tools and guidelines

The use of various guidelines to assist prescribers and other HCP’s is imperative. A few have been developed which hopes to support a path to reducing Polypharmacy, these include: Beers list and “the Stopp and Start tool”.

Public Health – Back to Basics

A focus on public health, raising awareness of diseases and creating micro-environments locally alongside a National consensus for change. If we can prevent/reduce the risk of a disease developing then Polypharmacy requirements may reduce. Examples of such an initiative are the Healthy living Pharmacies that have been on the increase in the UK.

Inferences

Please note, we are a great advocate for lateral thinking and would thus like to share my personal views. Below are inferences we have drawn and by no way reflect a definite fact (alongside the document itself).

Our Patients – Patients are at the centre of the NHS, and also at the centre of everything we do as Healthcare practitioners. Thus if the medicines optimisation process occurs effectively. There should be a reduction in Hospitalisation due to AE’s ( currently 17% of hospitalisations are implicated with Polypharmacy). However, it is important that care is taken to ensure HCP are still confident to prescribe medications when required. A fear of prescribing could lead to a negative effect for patients; denial of access to medicines could occur.

Community Pharmacy – Reduction in Polypharmacy should lead to a decrease in dispensing errors. Undoubtably, we assume it will lead to a decrease in Prescriptions and items. This will place an increased pressure on the already strained income of Community Pharmacist Business owners. Thus a shift towards more innovative practice, Pharmacy services and OTC sales is likely.

The NHS – we are a strong advocate for the notion “Save our NHS”. And hopefully, this should lead to a significant cost saving . For example if the average cost of a medication was £10, Patient X previously took 6 medications, which has been reduced post a medicines optimisation exercise to 5 medicines. This represents a cost Saving (£10×12) of £120 per year. This may not seem like a large amount, but once extrapolated to the wider population figures will become much significant. Furthermore, a reduction in medication waste should occur.

The Pharmaceutical Industry – It is only logical to assume that a reduction in prescriptions will lead to a reduction in sales and thus revenue of various companies in the industry. However, the situation could drive more innovation, as Pharmaceutical companies strive for new drugs (blockbuster drugs) or seek to extend the applications of current drugs (i.e. indications). The situation could also create an impetus for more collaborative work between the Pharmaceutical companies as they seek to provide evidence to support their current medications. Furthermore, we may see more factorial clinical trials which may assist in understanding Polypharmacy, it could also be beneficial for the Industry as it may lead to support for use of a particular medication. Finally, we believe the situation would lead to a closer relationship between the Pharmaceutical industry and the NHS. As both seek to find a joint solution, sharing expertise.

Why did we write this?

we have constantly experienced the effects of Polypharmacy personally, standing behind the Pharmacy counter while someone brings in a pile of medicines worth over £500 all going to waste as the patient has sadly passed away. Some of the medication pre-dating 4 years ago. Relatives rightfully worried that their loved one was supplied so many medications, some wondering how their loved one was expected to remember when to take all the medications. A well known fact is that most people dont take their medicines the way they are intended to be taken. we always wondered could that person still be alive had someone (HCP, Social worker or Pharmacist) taken time to thoroughly go through their medications with them.

Further reading

1. Kings Fund; PolyPharmacy and Medicines optimisation.

2. NHS scotland; Polypharmacy Guidance october 2012

3. Royal Pharmaceutical Society Scotland; Improving Pharmaceutical care in care Homes March 2012