Applying 7 Steps

Polypharmacy guidance: realistic prescribing
Scottish Government Effective Prescribing & Therapeutics Division
Polypharmacy icon of two pills

1. What matters to the patient?

  • Review diagnoses and identify therapeutic objectives
  • Patient reports: “I feel breathless whenever I have to rush or climbing the stairs; Do I really need to take so many pills; my ankles are getting really swollen”
  • Therapeutic objectives: Secondary prevention of cardiovascular events (incl. Stroke Prevention in AF); Rate control in atrial fibrillation; Management of CKD, COPD, diabetes and depression; Pain control

2. Need

  • Review need for essential drugs (stop only on expert advice)
  • Levothyroxine to treat hypothyroidism
  • Atenolol: for rate control in Atrial Fibrillation
  • Antidiabetic medication: diabetes symptom control

3. (Continued) Need for Drugs

Review need for unnecessary drugs – consider stopping or reducing dose (deprescribe)

  • Pain control: Is the gabapentin for neuropathic pain or mechanical back pain; co-codamol v paracetamol; NSAID required?
  • Antidepressant: is duration acceptable?
  • High dose omeprazole: Active peptic ulcer or oesophagitis? Are symptoms of gastric origin; may require endoscopy or trial without NSAID?

4. Effectiveness

Identify if therapeutic objectives are being met and whether therapy should be added or intensified

  • Secondary prevention of coronary events: likely to derive macrovascular benefit from tight glycaemic control; consider statin and BP control
  • Stroke prevention in atrial fibrillation: CHA2DS2-VASc score 4, so consider replacing aspirin with anticoagulant; check rate control
  • COPD management: symptom control (MRC Breathlessness Score); inhaler technique; formulary compliance
  • Pain control: discuss symptom control and review expectations; if gabapentin prescribed for back pain then consider withdrawal; review NSAID
  • Depression management: discuss symptom control
  • Hypothyroidism management: check TFT result
  • CKD management: check and monitor for proteinuria
  • Diabetic control: HbA1c high despite three antidiabetics; check adherence

5. Safety

Identify patient safety risks

Identify adverse effects

  • Actual ADR: Ankle swelling – due to amlodipine or pioglitazone?
  • Risk of GI bleeding: NSAID + citalopram + aspirin (or anticoagulant added)
  • Risk of acute kidney injury: NSAID + CKD (eGFR 55ml/min), consider stopping; co-prescribed diuretic + ACEI/ARB + NSAID (‘triple whammy’); co-prescribed thiazide and loop diuretic, stop one; increase U+E monitoring
  • Sick Day Rules Guidance: check awareness
  • Risk of cardiac events: NSAID + CHD – diclofenac (ibuprofen and naproxen preferred); pioglitazone (ankle swelling and ischaemic heart disease)
  • Risk of arrhythmia: QTc prolongation: omeprazole, citalopram and gabapentin

6. Cost-effectiveness

  • Opportunities for cost minimisation: generic substitution; formulary compliance; change liquid levothyroxine to tablet

7. Patient centeredness

Are the outcomes of the review clear?

Are changes the patients preferences?

Agree and communicate plan

 

  • Preferences and understanding:
    • Secondary CVD prevention: prioritise discussion that most effective intervention would be stopping smoking followed by anticoagulant for AF; BP control; addition of statin; weight reduction; HbA1C control
    • COPD management: check patient understands how to monitor breathlessness score, check inhaler technique and suitability
    • Non-medication interventions: Support and check willingness for lifestyle changes; signpost to social support, e.g. Alzheimer’s Scotland helpline