Polypharmacy and deprescribing

Appropriate Polypharmacy and deprescribing has long been a topic which is very popular with Commissioners, and of great importance to PrescQIPP to ensure patient safety.

This webkit outlines the work that we have done so far, and the work that we’re looking to do to support this prominent area of Medicines Optimisation. Please find a range of information, resources and ideas for this key area. Why not add to the resource by contributing your local work?

Polypharmacy and deprescribing - Appropriate polypharmacy

This webkit will gradually bring together all the PrescQIPP Polypharmacy and Deprescribing (P&D) resources and showcase good practice examples of projects focusing on medicines optimisation, medication review and appropriate polypharmacy gathered nationally and internationally. Some resources contain tools and templates that can be adapted for local use and implementation.

Polypharmacy and deprescribing - Definitions

There is often a lot of debate around what we mean by polypharmacy and, in particular, deprescribing. This is how we describe these two synergistic areas:

Polypharmacy is now recognised as two distinct types:

Appropriate Polypharmacy which is beneficial to a patient, e.g. the combination of medicines prescribed following a myocardial infarction. This requires ongoing assessment of the patient’s response to treatment to ensure all prescribed medicines remain appropriate and safe.

Potentially Inappropriate Polypharmacy which, for the individual, has become problematic as the harm outweighs the benefits and therefore the patient is taking more medicines than are clinically needed and no-one is really managing them, this is often due to multiple prescribers. Inappropriate polypharmacy is NOT just about taking multiple medications, it also occurs where a medicine no longer aligns with the goals of care, is an ineffective or unnecessary treatment, or has become high risk, particularly in patients with increasing frailty.

There is a need to promote a more 'Mindful Prescribing' attitude in all medication review opportunities and highlights that even one or two medicines may reflect inappropriate prescribing for some patients. This may also include the need to optimise medicines to ensure appropriate polypharmacy, e.g. beta blockers in heart failure titrated to correct dose. 

A Prescribing (or prescription) Cascade occurs when a new medicine is added to treat a side effect of another previously prescribed medicine, this is often misdiagnosed as a new problem and can result in both appropriate and inappropriate polypharmacy. It may lead to yet another iatrogenic problem and the cascade continues. A cascade can be reversed through deprescribing.

Deprescribing is synergistic with inappropriate polypharmacy and is the process of tapering, withdrawing, discontinuing or stopping medicines to reduce potentially problematic polypharmacy, adverse drug effects and inappropriate or ineffective medicine use by regularly re-evaluating the ongoing reasons for, and effectiveness of medication therapy. This should be done in partnership with the patient (and sometimes their carer) and supervised by a healthcare professional, it can be effective in reducing medication (pill) burden in patients to improve their quality of life while still maintaining control of chronic conditions. 

Deprescribing must be done judiciously, with monitoring, to avoid worsening of disease or causing withdrawal effects. This needs careful discussion on an individual basis to gain patient understanding and acceptance. It may be helpful to use different terminology for patients. Treatment and care should take into account individual needs and preferences. People who use health and social care services should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals and social care practitioners. It is recognised this is a complex process, not a single act, involving multiple steps. 

Gnjidic D, Le Couteur DG, et al. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing & clinical outcomes. Clin Geriatr Med 2012; 28: 237–253.

Reeve, E., Gnjidic, D., Long, J., and Hilmer, S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. British Journal of Clinical Pharmacology. 2015. 80(6), 1254-1268.

The PrescQIPP national polypharmacy and deprescribing review

Polypharmacy and deprescribing - The landscape

The 5 domains of the NHS outcomes framework all pertain to improving the quality, safety and experience of care for the most vulnerable, at-risk patients. Polypharmacy (or multiple medicines) to treat a number of Long Term Conditions is very common in this population. The needs of these patients are often complex, with many taking unnecessary, clinically ineffective, or unsafe combinations of medicines.

High levels of polypharmacy are often apparent in patients in care homes. Patients can end up on many drugs as a result of moving between different settings, e.g. hospital, GP and care home, with new items added to their drug regimen at each stage. This unintegrated, silo approach can mean patients take unnecessary or clinically ineffective medications, with economic and lifestyle implications, and potentially medicines that are harmful or unsafe. Impacts of polypharmacy can include: exaggerated side effects of medication (which is more pronounced in older people) resulting in yet more medicines being prescribed and subsequent increases in hospital admissions, medicines waste and the associated cost implications, and strain on time for patient care.

Research and practice from across the world has demonstrated the value of regular medication reviews to optimise medicines use and reduce the risk of adverse effects. The medication review may also include tapering, withdrawing and discontinuing medicines to reduce use of ineffective or inappropriate polypharmacy – a process of ‘deprescribing’. Whilst optimising medicines can improve the experience, quality of life and outcome for patients, there is evidence of a lack of confidence within the clinical support mechanisms around rational discontinuation and deprescribing. As a health system we are often hesitant to stop medicines..There is limited practical material and training to support prescribers in reviewing, prioritising or discontinuing medication, consequently many clinicians feel reluctant or unable to stop medications prescribed in another setting, and pharmacists, patients and carers feel unable to challenge prescribing decisions.

Research has also shown that doctors and patients actually agree about stopping long-term medicines use, which contradicts a widely held belief that patients don’t want medicines stopped. There is evidence to show that if given the choice, patients will choose to stop medications if there is medical consent or agreement.

In recent years a few resources have started to approach this topic, translating evidence that is available into clear terminology to help inform clinical decision making. Withdrawing medicines is difficult, so information to support health professionals deprescribe and address the complex, cultural barriers that exist within some stakeholder groups is needed. This is an area where there is strong support (see partners section), the benefits are seen as obvious, and yet inappropriate polypharmacy is still widespread and entrenched.

In response to this need, an intensive, integrated and practical approach is required to equip and upskill stakeholders to safely and appropriately discontinue treatment. Four key groups have been identified: GPs, community pharmacists, non- medical prescribers (e.g. nurses), and patients and their carers, with each having specific needs that require a separate, tailored approach.

Strategic Overview

Polypharmacy has been recognised and discussed for decades, but little has changed and patients are still prescribed many medicines on a continuing basis, often with insufficient or no reviews. This is a complicated area, some polypharmacy is appropriate, recent studies have shown that multiple prescribing does not always result in poor quality prescribing. However, it is known that some polypharmacy is potentially problematic and for this cohort of patients practice needs to change. Action is needed now to ensure patient safety and the reduction of waste leading to the consequent savings available to the NHS.

See our workplan for information on our polypharmacy planned work.

Ensuring appropriate polypharmacy - Flowchart

The flowchart shows the steps in the process to engage patients fully in decisions about their treatment.

B162: Agreeing treatment goals and discontinuation criteria

This bulletin, briefing and supporting resources support prescribers in being able to agree the goals of a treatment and discuss the discontinuation criteria with patients before they initiate a treatment. Tools are available to support the discussion with patients as well as identify the factors that should be considered before prescribing.

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Multimorbidity and frailty

Polypharmacy can play an important role in increasing a person’s life expectancy and quality of life, however this needs to be balanced with any potential harms of medicines and the risks of non-adherence. It is essential to optimise medicines to ensure safe prescribing and appropriate polypharmacy for patients with multimorbidity as well as increasing frailty or those moving towards end of life.

B153: Considerations in frailty

This bulletin focuses on frailty and end of life and the specific considerations that would apply to this group of patients when reviewing medicines/ considering stopping medicines.

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B190: Multimorbidity

This bulletin reviews the evidence around multimorbidity and polypharmacy. It supports the implementation of NICE guideline NG56. A template individualised patient management plan is included.

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Medication reviews

To ensure a reduction in potentially inappropriate (problematic) polypharmacy it is essential that regular, effective medication reviews are undertaken, particularly for vulnerable people, e.g. those with changing frailty.

There are many patients who need a full medication review, but there are limited resources to undertake these. This section offers guidance on: how to offer an effective medication review, prioritising your patients, suggestions for who can undertake a medication review, how to engage patients and a discussion on the ideal consultation length. Validated tools to support a medication review, and the NO TEARS adapted tool are also described.

B136: Ensuring appropriate polypharmacy - Medication review

This resource provides a strategic overview of polypharmacy and deprescribing, with summary and links to the validated tools that can be used to support medication review and highlights their benefits and limitations in practice.

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B152: Improving medicines and polypharmacy appropriateness clinical tool (IMPACT)

In 2011 PrescQIPP launched the Optimising Safe and Appropriate Medicines Use (OSAMU) Guidance: a pragmatic, evidence-based resource designed to be used in conjunction with other relevant, patient specific information.

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Safe and appropriate medicines use webinar

This webinar was presented by Katie Smith, Director - East Anglia Medicines Information Service and Valerie Shaw, Deputy Chief Pharmacist, Addenbrooke's Hospital.

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Optimising polypharmacy and deprescribing webinar

This webinar was presented by Katie Smith, Director - East Anglia Medicines Information Service and author of the PrescQIPP Optimising Safe and Appropriate Medicines Use Tool.

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B176: A practical guide to deprescribing

These resources provide some practical advice on deprescribing. Supporting tools include our first batch of deprescribing algorithms.

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B184: Behaviour change strategies

This bulletin introduces some of the key concepts around behaviour change and considers practical ways in which health professionals can use and develop their skills.

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High risk medicines

The PrescQIPP IMPACT project and the medication review documentation identifies some high risk medicines which it would be appropriate to prioritise for medication review. The materials below help support appropriate identification and review of patients taking these medicines.

B80: Opioid patches

The opioid patches bulletin focuses on the safe and appropriate prescribing of opioid patches as well as cost effective treatment choices. An audit is available to help support the review of patients already prescribed opioid patches to assess whether there is a continued need for treatment with patches.

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B132: Fentanyl

Immediate release fentanyl has a NICE do not do as a first line treatment for breakthrough pain. This bulletin which is a DROP list support bulletin will focus on fentanyl immediate-release formulations and provide the rationale for new patients to be commenced on immediate-release morphine.

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B62: Tramacet®

This bulletin focuses on Tramacet® (paracetamol 325mg/tramadol 37.5mg) and provides the rationale for new patients to be initiated on paracetamol or paracetamol with codeine. Current patients should be considered for a switch to paracetamol alone or paracetamol with codeine.

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B56: Oxycodone/naloxone prolonged release (Targinact ®) tablets

The bulletin and resources provide further information on the evidence base for for using oxycodone/naloxone prolonged release tablets, the rationale to stop treatment and also suggests alternative treatment options.

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B175: Hypnotics

Hypnotics should be prescribed for short term use only and within their licensed indications. If they have been prescribed long term (more than two weeks) withdrawal should be gradual to avoid adverse effects.

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B92: Safety of long term PPIs

The risks vs benefits of PPIs have been questioned in recent years. Continued long term use may cause serious adverse side effects and may contribute to the risk of C. difficile infection.

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Reducing antipsychotic use in dementia

The PrescQIPP reducing antipsychotic prescribing in dementia toolkit is a resource aimed at healthcare professionals and carers, which can be used to support these symptoms without the use of antipsychotics.

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Reducing antipsychotics in dementia webinar

In this webinar, Cherise Howson and Sajida Khatri showcase the resources in the reducing antipsychotics in dementia toolkit and discussed the evidence behind the recommendations.

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Antibacterials

Antibiotic resistance and the lack of new antibiotics being developed to replace ones for which resistance is a significant issue are still ongoing concerns. It is imperative that we do all that we can to preserve the usefulness of the antibiotics we currently have.

B137: Constipation

The constipation bulletin reviews the treatments available for constipation (including newer therapies) and provides advice and guidance on when they should be used and for how long.

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B96: Non-steroidal anti-inflammatory drugs (NSAIDs)

There are long-standing and well-recognised GI and renal safety concerns with all NSAIDs. There has also been an increase in CV safety concerns with NSAIDs. Therefore the substantial use of NSAIDs needs addressing.

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B140: Anticholinergic drugs

This bulletin discusses appropriate treatment with anticholinergic drugs. Support materials are available to identify the risk in patients and support appropriate action to reduce anticholinergic burden.

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Anticholinergic burden e-learning course

Our Anticholinergic burden e-learning course is CPD certified and available to all NHS registered users and subscribers for free. This course is for medicines management teams, GPs, practice nurses, practice pharmacists and non-medical prescribers.

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Education package for healthcare professionals

The concept of deprescribing is still new to many clinicians and this course explains the principles as well as practical advice as to how it can be undertaken. It has been designed for all clinical staff who are involved in the prescribing and review of medicines, including: pharmacists and pharmacy technicians within medicines management teams; practice pharmacists; nurses; and GPs. These resources have been developed to support face to face training that can be delivered in modules/ bite sized chunks.

Polypharmacy and deprescribing e-learning course

The CPD accredited e-learning course is broken down into bite sized modules that can be completed at your own time and pace and includes:

  • Definitions, descriptors and principles to ensure appropriate polypharmacy
  • Multimorbidity NICE Guideline NG56
  • Reducing the pill (medicine) burden in people with frailty and those moving towards end of life
  • Medicines optimisation and patient centred care
  • Shared decision making
  • Tools to support medication review
  • Four case studies to bring the theory to life
  • Quizzes for each module and a final assessment.
  • On successful completion of the course which requires a pass mark of 80% in the final assessment, you'll be issued with a CPD accredited certificate of completion. 

The e-learning package is free to access by subscriber medicines management teams only using a special promo code. If you are a member of a medicines management team, please contact your subscriber lead for details.

Access for other healthcare professionals including practice staff can be purchased either by the CCG/Health Board as a bolt on to subscription (for more information, please email help@prescqipp.info), or directly via PayPal by individual users for £12.50.

Access the polypharmacy and deprescribing e-learning course here.

Further reading

Key reports and links

Sharing polypharmacy and deprescribing resources

PrescQIPP supports innovation and sharing of resources to avoid duplication and to speed up the delivery of ideas. 

The examples listed here have not been validated by PrescQIPP through the usual QA process as they have been provided directly from organisations. If you want to use anything listed please acknowledge the original source in your locally adapted work.

If you would like to contribute your own examples please forward them, with a contact, to help@prescqipp.info

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