managing polypharmacy

1. Managing
Polypharmacy
Zeshan Ahmed
Practice Link Pharmacist
West London CCG

2. About me….
• Practice Link Pharmacist @ West London CCG
• 2 days a week @ St Charles centre for health and wellbeing
• MyCareMyWay
• Care homes Pharmacist @ Enfield CCG
• 102 care facilities
• Hospital pharmacist
• GSTT, Lewisham, North Middlesex

3. Agenda
Background
Polypharmacy ….in practice
Case studies
Useful resources

4. Shhh!…….The
“P” word………
Is it always bad ??

5. A new phenomena?
“We dislike polypharmacy as much as it is possible, and we would never
exhibit a remedy of any kind unless we had a scientific reason for so
doing and unless we were prepared to defend our method of
treatment….”
Newnham W. Remarks on the present aspect of medicine. Prov Med Surg J 1848;p281-285
Published 31st May 1848.
(The Provincial Medical and Surgical Journal was the forerunner to the British Medical Journal)

6. Definitions
• Problematic polypharmacy >
Is where prescribing of multiple medications inappropriately, or where the
intended benefit of the medication is not realised. The reasons for this may
be that the treatments are not evidence-based, or the risk of harm from
treatments is likely to outweigh benefit, or where one or more of the
following apply:
• No current, valid indication
• Pill burden adversely affecting adherence
• The drug combination is hazardous because of interactions
• Medicines are being prescribed to treat the side effects of other medicines where
alternative solutions are available to reduce the number of medicines prescribed

7. Definitions
• Appropriate polypharmacy >
Is 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. The
overall intent for the combination of medicines prescribed should be to
maintain good quality of life, improve longevity, and minimise harm
from drugs.

8. Why do we have Polypharmacy?
Living longer
TargetsGuidelines

9. What are the key problems?
• Drug-drug interactions
• Drug-disease interactions
• Sub-optimal therapy
• Redundant prescriptions
• Non-adherence

10. Deprescribing
• Harder to STOP than start > “if it ain’t broke, don’t fix it”
• The current model of prescribing is based very much around adding
drugs as patients develop more conditions
• The concept of de-prescribing involves carefully assessing patients’
medicines and (with patient and/or carer consent) withdrawing those
that may be harmful or no longer providing benefits
• Given the risks of adverse drug events (especially with the
'therapeutic cascade‘); problems with adherence, and limitations on
effectiveness, it is important to consider whether to discontinue some
medicines in some patients

15. Stopping meds – what to consider?
• Is the drug still needed?
• Has the condition changed?
• Can the patient continue to benefit?
• Has the evidence changed?
• Have the guidelines changed?
• Is the drug being used to treat an iatrogenic problem?
• Would discontinuation cause problems? Some therapies should not
be stopped abruptly following long-term use.
• What does the patient/carer think?

16. Medicines Optimisation….
• It need not be complex or fancy
• Most effective often the simplest
• Antihypertensives
• Laxatives
• Meds without a valid indication
• Historic prescribing
• e.g. Aspirin for primary prevention
• Don’t be afraid to ask “why” ?
• RATIONALISE therapy > polypharmacy isn’t bad if it is appropriate

17. Case study 1: Miss P, 58yrs – 28 repeat Rx’s!
• Amitriptyline 25mg ON
• Amitriptyline 50mg ON
• Aspirin 300mg MDU
• Betamethasone 0.1% ear/eye/nose drops
• Bisacodyl 10mg suppositories – ONE MDU
• Betnovate 0.1% ointment
• Cetraben cream MDU
• Cetraben emollient cream
• Fentanyl 25mcg patches
• Fentanyl 50mcg patches
• Fentanyl 75mcg patches
• Fultium-D3 800unit OD
• Glyceryl trinitrate 400mcg spray – MDU
• Hydroxyzine 25mg tabs
• Zineryt lotion - ON
• Naproxen 250mg – Up to 3 at the onset of
migraine as directed
• Ibuprofen 400mg tabs – ONE TDS
• Omeprazole 40mg caps – OD
• Oxycodone 5mg/Naloxone 2.5mg MR tabs – 2 BD
• Paracetamol 250mg/5ml oral suspension S/F – 1g
up to QDS for pain
• Paracetamol 500mg caplets – 1 – 2 QDS PRN
• Pepermint oil 0.2ml caps – MDU
• Progynova 2mg tabs – MDU
• Propranolol 160mg MR caps – OD
• Propranolol 80mg MT caps – OD
• Prucalopride 2mg tabs – OD
• Rizatriptan 10mg oral lyophilisates S/F – ONE MDU
• Senna 7.5mg tabs – 1-2 ON for constipation

18. Case study 1: Miss P, 58yrs – 28 repeat Rx’s!
• Amitriptyline 25mg ON
• Amitriptyline 50mg ON
• Aspirin 300mg MDU
• Betamethasone 0.1% ear/eye/nose drops
• Bisacodyl 10mg suppositories – ONE MDU
• Betnovate 0.1% ointment
• Cetraben cream MDU
• Cetraben emollient cream
• Fentanyl 25mcg patches
• Fentanyl 50mcg patches
• Fentanyl 75mcg patches
• Fultium-D3 800unit OD
• Glyceryl trinitrate 400mcg spray – MDU
• Hydroxyzine 25mg tabs
• Zineryt lotion - ON
• Naproxen 250mg – Up to 3 at the onset of
migraine as directed
• Ibuprofen 400mg tabs – ONE TDS
• Omeprazole 40mg caps – OD
• Oxycodone 5mg/Naloxone 2.5mg MR tabs – 2 BD
• Paracetamol 250mg/5ml oral suspension S/F – 1g
up tp QDS for pain
• Paracetamol 500mg caplets – 1 – 2 QDS PRN
• Pepermint oil 0.2ml caps – MDU
• Progynova 2mg tabs – MDU
• Propranolol 160mg MR caps – OD
• Propranolol 80mg MT caps – OD
• Prucalopride 2mg tabs – OD
• Rizatriptan 10mg oral lyophilisates S/F – ONE MDU
• Senna 7.5mg tabs – 1-2 ON for constipation

19. Case study 2: Mr H, 73yrs – 23rpt Rx’s
• PMHx: BPH, sciatica, fatty changes to liver, memory impairment, T2DM,
HTN, IHD, anxiety/depression, gout, obesity, lipids,
• Egfr: 58 – Jul 17
• BP: 112/70 – Jul 17, 112/76 – Jul 17, 146/80 – Jul 17 (<140/90)
• LIPIDS: TC – 4.1, LDL – 2.04} Jul 17
• HBA1c: 57 – Jul 17
• QRISK2: 39.69%

20. Your thoughts ??

21. 1. R/V need/efficacy of highlighted Rx’s?
2. BP is well controlled, consider  dose of ramipril to 5mg OD
3. Amitriptyline + promethazine + olanzapine > risk of sedations + S.E
a. Indication of for olanzapine?
b. Promethazine?
4. Testogel + sildenafil + EMLA > from sexual health clinic for premature ejaculation
a. Are these still valid? Last letter from clinic is June 2015
5. Why is he self-monitoring blood glucose > hypo’s? if no then stop
1.6.13 Do not routinely offer self-monitoring of blood glucose levels for adults with type 2
diabetes unless:
 the person is on insulin or
 there is evidence of hypoglycaemic episodes or
 the person is on oral medication that may increase their risk of hypoglycaemia while driving
or operating machinery or
 the person is pregnant, or is planning to become pregnant. For more information, see the
NICE guideline on diabetes in pregnancy. [new 2015]
6. Switch to atorva 20mg (has never had before)

22. Case study 3: Miss V.well controlled…..
• 92yrs old
• PMHx – HTN, t2dm, IHD, Hx of falls, cognitive impairment, CKD stage 3
• EGFR – 52ml/min
• BP – 109/64, 101/60, 111/65
• LIPIDs - TC – 2.6, LDL – 1.2
• HBA1c – 46mmol/mol

23. Meds….
• Metformin 1g BD
• Gliclazide 160mg OM, 80mg ON
• Aspirin 75mg OD
• Amlodipine 10mg OD
• Ramipril 7.5mg OD
• Atorvastatin 40mg ON
• Doxazosin 8mg OD
• Lansoprazole 15mg OD
• Senna 15mg ON
• Folic acid 5mg OD
• Fultium D3 20,000unit capsules – once monthly
• Alendronic acid 70mg weekly

24. NICE – NG28, Dec 15
• 1.1 Individualised care
• 1.1.1 Adopt an individualised approach to diabetes care that is
tailored to the needs and circumstances of adults with type 2
diabetes, taking into account their personal preferences,
comorbidities, risks from polypharmacy, and their ability to benefit
from long-term interventions because of reduced life expectancy.
Such an approach is especially important in the context of
multimorbidity. Reassess the person's needs and circumstances at
each review and think about whether to stop any medicines that are
not effective. [new 2015]

25. Repeat offenders…
• PPIs
• Folic acid
• Iron preparations
• Thiamine/Vit B
• Zopiclone!
• Seasonal preparations > nasal sprays/eye drops
• Antihistamines
• Emollients
• Antipsychotics!! (in dementia)

26. Useful resources
• STOPP START toolkit
• AWSMG polypharmacy guidelines
• NHS Highlands polypharmacy guidelines
• Kings Fund report - Polypharmacy
• NICE Multimorbidity guidelines