Polypharmacy Flashcards
What is polypharmacy?
From NICE:
* Use of multiple medicines by a person
From workbook and google:
* When a patient is regularly prescribed and uses multiple medications at one time.
(said 5+ online but said 6 meds in workbook)
What is a medication review?
A structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about:
* treatment,
* optimising the impact of medicines,
* minimising the number of medication-related problems,
* reducing waste
What patients should be prioritised for a structured medication review (in primary care)?
- Pts in care homes
- Complex and problematic polypharmacy - e.g. pts on 10+ meds
- severe frailty
- isolated or housebound
- pts who have had recent hospital admission/frequent hosp adm
- pts who have had a recent fall
- pts on addictive pain management meds
- Pts with co-morbidities
- Pts who use meds with narrow theraputic window
- Pts whos meds have high ADRs
What is appropriate polypharmacy?
defined as prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been
optimised and where the medicines are prescribed according to best evidence.
What is problematic polypharmacy?
defined as the prescribing of multiple medications inappropriately, or where the intended benefit of the medication is not realised
Why can prescribing to a pt who uses multiple drugs be problematic?
- the drug combination is hazardous because of interactions
- the overall demands of medicine-taking, or ‘pill burden’, are unacceptable to
the patient - these demands make it difficult to achieve clinically useful medication adherence
(reducing the ‘pill burden’ to the most essential medicines is likely to be
more beneficial) - medicines are being prescribed to treat the side effects of other medicines where
alternative solutions are available to reduce the number of medicines prescribed.
What tool can be used in a medication review?
STOPP-START toolkit
NO TEARS
Describe the STOPP-START toolkit
- recognise medicine safety concerns:
- STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions
- START suggests medications that may provide additional benefits e.g. proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
When reviewing/prescribing medciations to older people, what are the important pharmacokinetic and pharmacodynamics to be aware of?
- Renal function - declines with age. So need to be aware of renally excreted drugs
- Reduction in drug receptor sites / Increased sensitivity
- Reduction in first pass metabolism
- Reduction in GI absorption and motility
- Body composition changes - reduced body water, more fat deposition
- Reduction in hepatic function
- Reduced haemostatic reserve
- Reduced baroreceptor sensitivity (anti-HTN drugs)
What are the main issues with polypharmacy in older people?
- forget to take medications
- DDIs
- cognitive impairments
- ADRs - e.g. falls
- medications added to combact side effects of other medications.
What can be done to help patients remember to take meds?
- dossete boxes
- pill alarm box / vibration box
- visual cues - post it notes, put them in plastic cup e.g. near kettle when they make morning tea/coffee
- set timer on device/phone
- Call from family/friend
- Phone app reminder
What medicine aids can be given to patients finding it hard to dispense/use/swallow medication?
- Packets can be hard to open - need easy open dispenser box/blister pack
- Opticare eye drop aid
- Tablet popping device
- Haleraid - holds inhaler so easier to push
- AeroChamber
- Pill crusher
Brain dump any types of medications you would review
- Antidepressant
- Antihistamines
- Antispasmodics
- Antimuscarinics
- Loop diuretics
- Inhalers
- DM meds
- Anticoagulants
- Antiemetics
- Sedatives
- Drugs for Parkinson’s disease
- ACEi
- Analgesics - non-opiod and opiod
- Anticonvulsants
What is multi-morbidity?
Two or more co-existing long term medical conditions
BUT - not all long term conditions have the same impact on the person
Describe what we mean by trade-offs (regarding multimorbidity and polypharmacy)
When a person has multi-morbidity, it is often unrealistic to treat each condition perfectly, due to
* DDIs
* Increased side effect burden
* Increased risk of adverse effects in frail people
* Questions over the effectiveness of drugs in frail/multimorbid population
Professional approach is disease specific, not person specific
* we focus too much on ‘single system’ disease
We need to optimise medications, and consider trade-offs = the choice between the expected beneficial and harmful effects in terms of patient survival and quality of life for a particular medical treatment.
