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.
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
Over the summer of 2014 PrescQIPP launched the National Polypharmacy and Deprescribing Landscape Review receiving a significant amount of responses from a range of clinical stakeholders.
We have now published a summary report available for everyone to view, along with the summary responses and a presentation by Katie Smith, Director of East Anglia Medicines Information Service, on the findings. Please find the file linked below:
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.
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.
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 increasing frailty or moving towards end of life.
B153: Considerations in Frailty
This bulletin focuses on frailty and end of life and the specific considertaions that would apply to this group of patients when reviewing medicines/ considering stopping medicines. Medicines that should usually be continued and those with increased potential to cause harm are highlighted in the full bulletin with evidence-based tools to help the review process.
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
Evidence demonstrates we need to look beyond the health care professional telling a patient to take a medicine (and assume this happens) at a much wider picture. We need to understand and address not only patients' beliefs and behaviours, but also those of their healthcare professionals and their carers, such as family or friends, who help support them.
This resource provides a summary and links to the validated tools that can be used to support medication review and highlights their benefits and limitations in practice.
This resource describes best practice.
Tools to Support Medication Review
This resource provides ideas to help patients and health care professionals make the best use of the time in a medication review.
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. This was updated in 2016 to Improving Medicines and Polypharmacy Appropriateness Clinical Tool (IMPACT). Sectioned into BNF chapters, it identifies clinical and cost benefits with recommendations and considerations for appropriately continuing or stopping medicines. The document was originally produced as a PrescQIPP bulletin following a literature review which found little evidence about the practicalities of stopping medicines but large numbers of tools for reviewing potentially inappropriate medicines and various papers advocating the positive impact of stopping medicines if no clinical need exists.
The original OSAMU document was used by GPs, pharmacists and geriatricians during medication reviews in care homes, conducting collaborative discussions with the patient, nurse and GP. It was used in eight care homes during 235 multidisciplinary medication reviews and resulted in the safe and appropriate discontinuation of 398 medicines and ensured patients were prescribed the essential medicines they required. It is an education tool and provides a reference source for clinicians. Reported outcomes included: reduced polypharmacy, potential interactions and adverse effects, reduced medicine administration time and consequently increased time for patient care, reduced medicine waste and costs and reduction in the overall number of medicines taken, which was welcomed by patients.
The current bulletin can be downloaded via the link below and supporting resources can be found in other parts of this webkit:
Optimising Safe and Appropriate Medicines Use (OSAMU) Webinars
Over the past couple of years we have held two webinars to introduce our work, and also look at the changing landscape around this area. Both of these are freely available, last around an hour each, please watch them below.
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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.
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 to support behaviour change and empower patients around shared decision making and self management.
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 in the sliders below help support appropriate identification and review of patients taking these medicines.
PrescQIPP have developed several bulletins relating to opioid analgesics which include opiate patches, fentanyl immediate release and oxycodone MR/oxycodone & naloxone prolonged release (Targinact®). When reviewing treatment consider if the pain is still severe enough to warrant a regular opioid as the risk of falls or constipation can outweigh the benefits of treatment. Consider non-pharmacological options or switch to regular paracetamol.
The current bulletin, briefing and patient letters can be downloaded via the links below:
Hypnotics should be prescribed for short term use only and within their licenced indications. If they have been prescribed long term (more than two weeks) withdrawal should be gradual to avoid adverse effects.
Proton Pump Inhibitors (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. Check if there is a valid indication for prescribing e.g. is an NSAID still being taken.
In asthma the use of inhaled corticosteroids should be reviewed every 3 months and stepped down when appropriate.
In COPD – if an inhaled corticosteroid is not appropriate, a long acting antimuscarinic bronchodilator can be used with a long acting beta2 agonist.
The PrescQIPP Respiratory Care Webkit has tools and searches to support the review of respiratory patients.
Reducing Antipsychotic Use in Dementia
The use of antipsychotics in dementia to control behavioural and psychological symptoms has been a concern for many years.
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. The toolkit contains resources to support assessment of symptoms and use of non-pharmacological treatment in these patients and also resources to support the reduction in antipsychotic prescribing in those already being prescribed these drugs.
Reducing Antipsychotics in Dementia Webinar
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. Because antibiotic prescriptions tend to be acute prescriptions, once the prescription is written and dispensed, it is too late to do anything about this. Hence, it is imperative that antibiotic prescribing is audited on a regular basis and prescribers are frequently reminded of the antibiotic prescribing messages.
The PrescQIPP tools below help prescribers to audit their practice and benchmark against others.
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. Patient information, an audit and a template pathway document are available as supporting resources.
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.
There are a number of PrescQIPP resources that can be downloaded from the link below, these include bulletins, briefings, template patient letters and search criteria:
This bulletin discusses appropriate treatment with anticholinergic drugs. An increasing number of systematic reviews and meta-analyses report that drugs with anticholinergic effects are associated with an increased risk of cognitive impairment and all cause mortality in older people. Support materials are available to identify the risk in patients and support appropriate action to reduce anticholinergic burden.
Anticholinergic Burden e-Learning Package
Our Anticholinergic burden e-learning course is CPD certified and available to all NHS registered users and subscribers for free.
Links to other PrescQIPP webkits which support medication review
Below we have linked to other PrescQIPP webkits, which have useful resources within them and tools, which can support medication review in appropriate patients.
The PrescQIPP DROP-List
The DROP-List supports the review of low priority treatments that are not clinically or cost effective. They may be treatments that have a NICE 'do not do' recommendation attached to them or may be more suitable for self-care or over the counter purchase with the support of community pharmacists. Some of these treatments have little or no robust clinical evidence to support their use. View the DROP-List here.
Care Homes Webkit
The Care Homes webkit brings together all the PrescQIPP care homes resources and showcases good practice examples of projects focusing on medicines optimisation in the care homes setting. Each set of resources contains tools that can be adapted for local use before implementation. View the Care Homes webkit here.
Self Care Webkit
The Self Care webkit brings together all the PrescQIPP self care resources and campaign materials as well as showcase good practice examples of projects in self care and signpost to self care resources available for organisations to use to support their own self care campaigns.
Tools include project planning materials as well as campaign materials for different common ailments which can be treated as self care with the support of a pharmacist. The campaign materials will all follow the same format so that healthcare professionals and patients become familiar with them. View the Self Care webkit here.
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 Training Package
An accompanying Polypharmacy and Deprescribing e-learning package is also available.
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 firstname.lastname@example.org), or directly via PayPal by individual users for £12.50.
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 email@example.com
2015 Innovation Award Winner - North Derbyshire and Hardwick CCG – Deprescribing - GP Practice Protected Time
The MMT wanted to provide an introduction to the concept of “deprescribing”, provide some feedback from a local practice and give practice staff the opportunity to consider how they could incorporate these ideas into their daily work. This was dome through the local delivery of a two-hour session. More information available here.
Polypharmacy and Deprescribing Projects
North Tyneside CCG - Pills: Reviewing medication in care homes. This film tells the story of how the wellbeing of older care home residents is enhanced by making sure they are only prescribed the medicine they really need, and the positive impact this has had on the people who work on the project too.
Checklists, Referral Forms and Templates
Polypharmacy and Deprescribing
Stop List, Cost Effective Choices and supporting documents used in The Health and Social Care Board in Northern Ireland (NI)
In NI deprescribing or switching of certain medicines has been on-going for many years at a central level. Their national resources are available here, including the Prescribing Stop List, letters to support the process that highlight who can help achieve the outcomes and a list of suitable alternatives for some medicines that have a priority assigned to show where the greatest efficiencies can be achieved.
It is recognised that other healthcare systems may be different , but the opportunities our NI colleagues highlight may help others.
Polypharmacy and Deprescribing Virtual Professional Group
Why not join the Polypharmacy and Deprescribing Virtual Professional Group chaired by Val Shaw? We are a group of NHS staff who meet quarterly via a teleconference or webinar where we discuss ideas to reduce inappropriate polypharmacy and share examples of good practice. To join this group please complete the form below.
Next meeting: 13.00 - 14.00, 30 September
You can find out more about how we are helping subscribers to collaborate during our Year of Community.