Polypharmacy and the complexity of deprescribing medications – Dr Kinda Ibrahim

Dr KInda Ibrahim
Dr KInda Ibrahim, is a Senior Research Fellow based in the Faculty of Medicine at University Hospital Southampton

The concurrent use of 5 or more medications by one individual – is becoming increasingly a challenging phenomenon that demands attention at clinical policy and practice level. In the past decade, the average number of items prescribed for each person per year in England has increased by 53.8% from 11.9 to 18.3. It is 35-50% of community older people aged 65 years and above take 5 or more medications. The King’s fund ¹ published in November 2018 a report “Polypharmacy and medicines optimisation: Making it safe and sound” where they distinguished between the terms ‘appropriate’ and ‘problematic’ polypharmacy.

Appropriate polypharmacy: means prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and the medicines are prescribed according to best evidence.
Polypharm cartoon

Problematic polypharmacy where multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realised.

What are the factors contributing to polypharmacy?

A number of factors have been contributing to the development of polypharmacy in older people including:

  •  The growth of an ageing population
  •  The rising prevalence of multi-morbidity
  •  Multiple prescribers
  •  The evolution in drug discovery- the increased number of drugs approved every year
  •  Single disease guidelines and the absence of guidelines to manage multiple diseases
  • Cascade prescribing- where a medication is being started to treat the side effect of another medication
  •  Repeat prescribing system

What are the consequences of problematic polypharmacy?
The consequences of polypharmacy is massive and especially among older people living with frailty and/or dementia. Polypharmacy can result in increased adverse drugs events, drug-drug interactions and hospitalisation. If a person is taking ten or more medicines they are 3x more likely to be admitted to hospital. Adverse drug reactions are responsible for 6.5% of hospital admissions. Polypharmacy can also increase risk of falls, cognitive impairment, functional decline, increased health care usage and mortality.

In frail older people, using drugs to treat multiple conditions and prevent future illness may not be the best strategy; indeed, such strategies may well adversely impact on quality and duration of life. A recent systematic review by Marta Gutiérrez-Valencia et al ² 2018 identified 25 papers examining the relationship between polypharmacy and frailty, with 20 papers conducted among community-dwelling older people ¹. They suggests frail people are more likely to receive polypharmacy compared to non-frail individuals. They also reported that polypharmacy is associated with mortality, incident disability, hospitalization, and emergency department visits in frail and pre-frail older adults, but not in non-frail adults.

So what is the solution for problematic polypharmacy?
The obvious solution is to reduce polypharmacy by stopping problematic medications. De-prescribing is “the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes”. Guidelines focus on when to initiate a medicine, but there is far less information and evidence to help support decisions to stop therapy. Optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes. The goal of deprescribing is to reduce medication burden and maintain or improve quality of life.

Deprescribing as shared decision process
Key to deprescribing, as with all medical interventions, is the active participation of the patient to ensure that their preferences and choices are taken into account. Barnett NL et al ³ 2016 produced a Patient-centred approach for the management of polypharmacy which is designed to allow a collaborative approach of deprescribing involving both patients and clinicians.
Poly depres cycle edited

Qualitative research has revealed that medical practitioners recognize the need for shared decision making when considering medication cessation, and the majority of patients want to be involved in the decision-making process, even if they prefer to leave the final decision up to their primary care practitioner (GP). Stopping medication should be actively managed by the doctor, but remain the property of the patient.

It has been suggested that medicine optimisation and deprescribing should involve a multidisciplinary team where a pharmacist, a GP doctor and a geriatric consultant are actively engaged in the process. The feasibility of implementing this approach is clinical practice is yet to be evaluated. Many frail older people receive comprehensive Geriatric Assessment (CGA) by a geriatric consultant who performs a holistic assessment of patients’ needs including medications taking. CGA clinics could be an opportunity to discuss and initiate deprescribing, ideally with involving clinical pharmacists.

The Deprescribing process
Deprescribing medication is a complex process and could be organised at 3 stages. Remember that patients should be involved in every stage and their treatment goals and views about medication should be elicited and taken into account.

Dpres process

Stage 1: identifying patients at risk of inappropriate polypharmacy
The first of the deprescribing process involves identifying people who might benefit from a medication review. NICE guidelines suggest that patients aged 65 years and above who are taking 10+ medications and all residents in care home aged 50+ regardless of the number of medication should be targeted for medication review.

Other useful indicators include the Polypharmacy prescribing comparators which have been developed by the NHS Business Services Authority in conjunction with Wessex Academic Health Science Network (AHSN). These comparators allow identification of the percentage of patients prescribed 8 or more unique medicines, 10 or more unique medicines, 15 or more unique medicines, 20 or more unique medicines in a GP practice. It can also allow identifying people with an anticholinergic burden score of 6 or greater, 9 or greater, 12 or greater or those prescribed multiple anticoagulant regimes or prescribed medicines likely to cause Acute Kidney Injury (DAMN Drugs).

Another possible method of identifying high risk older people is using the electronic frailty index (e-FI). A score > 0.16 was shown to be correlated to patients experiencing potentially inappropriate medication and adverse drug reaction.

Stage 2: identifying inappropriate medications to stop
A 2014 systematic review identified 36 different tools for assessing inappropriate prescribing on the older population. The most commonly used ones are explicit tools (STOPP/START, STOPPFrail, Beers criteria, and Anticholinergic Burden Risk Scales) and implicit tools (NO TEARS, PINCER Indicators, Medication appropriateness index (MAI), NHS Scotland 7-steps). There are pros and cons for each type of these tools and good practice to use a combination of both (explicit tool+ implicit tool). The Beers Criteria and STOPPfrail are quick tools to flag specific medications or medication classes, and the MAI helps to clinically evaluate the remaining medications for things like whether the medication is indicated, effective for the condition and fit with the patients’ goal.

Stage 3: deprescribing and monitoring
When an agreement with the patient is achieved to stop a medication, the question will be which medication to stop first? How to priortise medications? Could more than one medication stopped at a time? can the medication be stopped abruptly or should be tapered? How long does the patient need to be followed up? What should be monitored? How frequent? And finally how to decide whether medication could be stopped completely or whether the patient needs to go back on medication?

These questions are challenging and there is little evidence to inform the deprescribing process. Sometimes, when reducing medications, adverse drug withdrawal events can happen. These are like side effects of stopping medications. It could be as simple as worsening pain while reducing dose of a pain medication. Or, it could be more serious. Some medications need to be reduced slowly to avoid withdrawal effects. Researchers suggest that it is a good practice to stop one medication at a time and to taper it down.

For the last few years a research group in Canada (the Bruyère Research Institute ⁴) has developed guidelines and useful tools and algorithms to aid deprescribing of specific medications including Proton Pump Inhibitors (PPI), Antipsychotics, Benzodiazepine,  Antihyperglycemic and Cholinesterase Inhibitors (ChEIs) and Memantine. These resources could be helpful and might encourage clinicans on at least deprescribe some of these commonly used medications in older people.

Key messages

  • Deprescribing is a process of planned and supervised tapering or ceasing of inappropriate medicines
  • Deprescrining is a multidisciplinary approach that should involve (patients, GPs, Pharmacists, and geriatric consultants) Key to deprescribing is the active participation of the patient to ensure that their preferences and choices are taken into account. Shared decision making should be an integral part of the deprescribing process
  • Deprescribing as well as prescribing should be integrated in the teaching of all undergraduate and postgraduate courses in medicine, pharmacy, nursing, physiotherapy, and other clinical areas
  • Cultural and behavioural shift: “the term ‘life-long medication’ should be removed from health care professionals’ vocabularies and replaced with ‘time-to-review’ expiry dates”

References
1-      Kings fund Noveber 2018. Polypharmacy and medicines optimisation: Making it safe and sound  https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation
2-      Gutiérrez-Valencia M, Izquierdo M, Cesari M Casas-Herrero Á Inzitari, Martínez-Velilla The relationship between frailty and polypharmacy in older people: A systematic review. Br J Clin Pharmacol. 2018 Jul;84(7):1432-1444. doi: 10.1111/bcp.13590. Epub 2018 May 3.
3-      Barnett NL, Oboh L, Smith K Patient-centred management of polypharmacy: a process for practice Eur J Hosp Pharm 2016;23:113-117.
4-      https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
5-      Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine. 2017;38:3-11.

 

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