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Polypharmacotherapy

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

polypharmacy may be defined as 'The administration of more medications than are clinically indicated' (1)
- another term is 'inappropriate medication use' - medication use that has a greater potential risk for harm than benefit, is less effective or more costly than available alternatives, or does not agree with accepted medical standards. However, there is still considerable disagreement among experts regarding what exactly is inappropriate medication use and how it can be determined
- Beers (3) tried to establish criteria for defining groups of drugs or specific medications that should be regarded as 'potentially inappropriate' and should not be given to elders in nursing homes or nursing departments
  - the list of medications that are 'potentially inappropriate' has been updated by the Journal of the American Geriatric Society is available here

Drug review process in the management of potential polypharmacy

this review should be undertaken in the context of holistic care considering each medication and its impact on the individual clinical circumstances of each patient. As part of this it is important to consider the cumulative effects of medications.

	CRITERIA / CONSIDERATIONS	PROCESS/GUIDANCE	References / Further reading or Examples
1	Is there a valid and current indication? Is the dose appropriate?	Identify medicine and check that it does have a valid and current indication in this patient with reference to local formulary. Check the dose is appropriate (over/under dosing?)	e.g. PPIs- use minimum dose to control GI symptoms - risk of c.difficle and fracture e.g. long term antibiotics
2	Is the medicine preventing rapid symptomatic deterioration?	Is the medicine important/essential in preventing rapid symptomatic deterioration? If so, it should usually be continued or only be discontinued following specialist advice.	e.g. Medications for Heart failure, medications for Parkinson's Disease are of high day to day benefit and require specialist input if being altered. review of doses may be appropriate e.g. digoxin
3	Is the medicine fulfilling an essential replacement function?	If the medicine is serving a vital replacement function, it should continue.	e.g. thyroxine and other hormones
4	Consider medication safety Is the medicine causing: Any actual or potential ADRs? Any actual or potentially serious drug interactions?	Contraindicated drug or high risk drugs group? Strongly consider stopping Poorly tolerated in frail patients? Consider stopping Particular side effects? May need to consider stopping	BNF Sections to Target
5	Consider drug effectiveness in this group/person?	For medicines not covered by steps 1 to 4 above, compare the medicine to the 'Drug Effectiveness Summary' which aims to estimate effectiveness.	Ref. Drug Effectiveness Summary
6	Are the form of medicine and the dosing schedule appropriate? Is there a more cost effective alternative with no detriment to patient care?	Is the medicine in a form that the patient can take supplied in the most appropriate way and the least burdensome dosing strategy? Is the patient prepared to take the medication? UKMI Guidance on choosing medicines for patients unable to swallow solid oral dosage forms should be followed.	Consideration should be given to the stability of medications. Ensure changes are communicated to the patients' Pharmacist: Would this patient benefit form Chronic medication Service?
7	Do you have the informed agreement of the patient/carer/welfare proxy?	Once all the medicines have been through steps 1 to 6, decide with the patient/carer/or welfare proxies what medicines have an effect of sufficient magnitude to consider continuation/discontinuation.

For full details then see Polypharmacy Quick Reference Guidance for Clinicians October 2012

Notes:

practical considerations
- often drugs are not discontinued after the problem has resolved such as:
  - digoxin taken after AF has reverted to sinus rhythm
  - analgesics taken after an exacerbation of osteoarthosis has settled
- renal and hepatic decline:
  - reduced renal and hepatic function make the elderly susceptible to interactions and side effects
  - creatinine clearance falls with age even in good health and despite a normal serum creatinine
  - metabolic or other adverse effects of treatment are so common that they form part of the differential diagnosis of any unwell elderly patient

Reference:

1) Hanlon J, Schmader K, Rubi C, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001;49:200-9.
2) Morton AH. Inappropriately defining 'inappropriate medication for the elderly.' J Am Geriatr Soc 2004;52:1580.
3) Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997;157:1531-6.

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