Polypharmacy

Question 1

How and why does Polypharmacy occur?

Answer 1

It is often due to the patient experiencing more than one health condition, we call these people complex patients. such as Diabetes, stroke and Depression

Question 2

What is multi-morbidity?

Answer 2

the co-occurrence of two or more chronic medical conditions in one person.

Question 3

What is Polypharmacy?

Answer 3

The use of many medicines together (often more than four or five medicines), or a medicine not matching a diagnosis.

Question 4

What is hyperpolypharmacy?

Answer 4

Use of ten or more regular medicines by an individual. This is also sometimes Called major polypharmacy or excessive polypharmacy.

Question 5

Define Appropriate polypharmacy

Answer 5

Multiple medicines, all of which are clinically indicated and accepted by the individual as improving their wellbeing and achieving the health outcomes that are important to them.

Some medical conditions are best treated with multiple medicines, for example, congestive heart failure, HIV infection or diabetes.

Question 6

What is Oligopharmacy?

Answer 6

The deliberate avoidance of polypharmacy, ie, using fewer than five regular medicines and minimising the number of doses an individual has to take in their day.

This approach is growing in popularity in end-of-life care but may also be useful for individuals who place a high value on taking fewer medicine

Question 7

Define Problematic PolyPharmacy

Answer 7

Also referred to as inappropriate polypharmacy. More medicines than an individual needs to achieve the health outcomes that are achievable and important to them, medicines that are having a negative impact on the individual’s wellbeing, medicines that are not adding any value, medicines that result in drug-drug or drug-food interactions or any other negative impact on the individual’s lifestyle that could be avoided

Question 8

Problematic medicines can be changed to an appropriate alternative or solved by….

Answer 8

Deprescribing

Question 9

Define Deprescribing

Answer 9

The process of stopping or reducing medicines with the aim of eliminating problematic polypharmacy, and then monitoring the individual for unintended adverse effects or worsening of disease.

It is essential to involve the individual (and their carer) closely in deprescribing decisions in order to build and maintain their confidence in the process.

Question 10

Define Pseudopolypharmacy

Answer 10

The healthcare record suggests polypharmacy but the individual does not take all the medicines on their prescription/medicines list.

This can occur when medicines are stopped by the individual or a prescriber but, for a number of reasons, not removed from the repeat prescription.

Question 11

Ms F (89 years old) has terminal pancreatic cancer and is under an end of life pathway. Her regular medication regime has been adapted to feature less than five medications. What type of polypharmacy is this?

Answer 11

Oligopharmacy

Question 12

Mr S (47 years old) suffers from diabetes and is prescribed metformin 500mg TDS with food, gliclazide 80mg BD with food, ramipril 5mg OD, bendroflumethiazide 2.5mg OM and simvastatin 40mh ON. What type of pharmacy is this?

Answer 12

Polypharmacy

Question 13

Mrs Q (62 years old) suffers from diabetes, heart failure and atrial fibrillation. She is prescribed a total of 12 different medicines to be taken through-out the day. What type of Pharmacy is this?

Answer 13

Hyperpolypharmacy

Question 14

How transfer of care could lead to polypharmacy?

Answer 14

Moving between care settings has been shown to result in polypharmacy, for example, a patient may transfer between hospital, general practice and a care home, with new medicines being added at each stage3. There is evidence that patients are discharged from hospital with an average of one-and-a-half more medicines than they were admitted with4. When patients transfer between different care providers there is a greater risk of poor communication and unintended changes to medicines.

When patients move from one care setting to another, between 30 and 70 percent have an error or unintentional change to their medicines

Question 15

What is reflex prescribing?

Answer 15

The prescribing cascade occurs when an adverse drug reaction is misinterpreted as a new medical condition. New medicines are started in order to manage the unrecognised side-effects of an existing medicine2.

Alternatively, a patient may end up in a situation where a prescribing vortex has occurred, in which each medicine causes a side-effect that is treated by the next.

Question 16

Mr S (72 years old) suffers from diabetes, congestive heart failure, and had a stent fitting last year. He is prescribed seven different medications, two of which have an adverse effect of gastro-intestinal irritation.

Over the last 2 months, he has presented at A&E twice and visited the GP three times where he saw the locum practitioner each time, with them all prescribing different therapies but not ceasing the previous hospital treatment as they did not want to interfere with the hospital specialist.

Answer 16

multiple precribers

Question 17

Mrs T (88 years old) was in hospital being treated for a fracture due to a fall in her home. Before admission, she was taking lansoprazole 15mg OD, aspirin 75mg OD, atorvastatin 20mg ON, and amlodipine 5mg.

Upon admission, she was started on naproxen 500mg TDS and her lansoprazole was swapped to omeprazole in line with the hospital formulary.

When she was discharged, she moved to a nursing home as she was deemed to require support with some daily aspects of her life. The hospital informed her GP practice that the naproxen should be continued for two more weeks, they also discharged her with omeprazole which was added to the GP repeat form.

Her new prescription arrives from the pharmacy and it contains both omeprazole and lansoprazole.

Answer 17

Transfer of care

Question 18

Ms Q (55 years old) was prescribed alendronic acid 70mg once a week, to help prevent postmenopausal osteoporosis.

She started experience acid reflux on the day she took the medication so was prescribed omeprazole 20mg OM as a result.

When the GP was preforming her review, Ms Q reported she was having trouble sleeping so the doctor prescribed her zopiclone 3.75mg ON.

The following week Ms Q visits her pharmacy as she has developed a slight skin rash, which she finds causes discomfort occasionally so the pharmacist sells her some loratidine.

Answer 18

Reflex prescribing

Question 19

Examples of a trigger question a patient should be asked

Answer 19

How are you getting on with your medicines?
Allows patients to communicate their concerns
Do you need help getting a regular supply of your medicines?
Identifies access issues
Do you always take all of your medicines the way that the doctor wants you to?
Identifies adherence issues
Can you swallow and use all of your medicines and get all of your medicines out of their containers?
Identifies day-to-day management issues
Do you think that some of your medicines could work better?
Identifies clinical issues

Question 20

State ways to communicate and support patient

Answer 20

Encourage patients to express their feelings
Put yourself in your patient’s shoes, what does the patient want to get out of their medication?
Use a shared decision-making approach to involve the patient
Ask if they would like to discuss their options with someone else in their family or a member of the team
Reassure them that they can come back and discuss their medicines and review any decisions.

Question 21

Tools to assist in communicating with patient

Answer 21

STOPPSTART tool kit

Question 22

State the advantages of using the STOPPSTART toolkit

Answer 22

Can be applied with little clinical judgement & Low cost

Question 23

State the disadvantages of the STOPPSTART toolkit

Answer 23

Doesn’t take into account patient preferences or co-morbidities

Question 24

List the 7 step approach to medication Review

Answer 24

1. Identify the aims and objective of drug therapy
2. Identify essential drug therapy
3. Does the patient take unnecessary drug therapy?
4. Are therapeutic objectives being achieved?
5. Is the patient at risk of ADRs or suffers actual ADRs?
6. Is drug therapy cost-effective?
7. Is the patient willing and able to take drug therapy as intended?