The AHSN Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Mind over bladder - Prevent harm associated with excessive or inappropriate anticholinergic burden, can be viewed here. For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/

1. Learning and Development from
Polypharmacy Action Learning Sets
Impact of DAMN drugs reviews
in Dudley
What did you do differently post ALS when you
returned back to your place of work?
The polypharmacy working group have been reviewing
the Polypharmacy indicators available on ePACT2. As an
ICB we have some work to associated with kidney
injury: Percentage of patients prescribed an NSAID and
one or more other unique medicines likely to cause
kidney injury (DAMN drugs) aged 75 and over.
Identifying and conducting medication reviews on
patients falling into this group will enable adjustments
to be made that reduce the risk of AKI.
The Dudley model can be shared and educational
materials and also engaging with national initiatives
such as World Kidney Day to promote the messages to
patients and HCPs
How did you decide which area to focus on, why and
how did you do this?
I have an interest in renal and diabetes medicine and
this lead me to combine my knowledge from these
areas with the learning from the polypharmacy ALS.
Typically renal patients have polypharmacy due to
multimorbidity and also symptom control with CKD.
The DAMN drugs data reveals that Dudley and the
Black Country are generally doing well as a region when
compared to the rest of England with DAMN drug
deprescribing. However with the updates to the NICE
diabetes guidelines and use of SGLTis and also the
changes in licensing for SGLT2i, it is pertinent to carry
out further work on this area to improve outcomes
locally and build on the work that has already been
carried out.
Recommendations following pilot:
• Identify patients prescribed an NSAID and
one or more other medicines likely to
cause AKI aged 75 years and over. Carry
out a SMR with a view to reducing AKI
risk by using sick day resources.
• For osteoarthritis care consider
deprescribing of PPI where NSAIDs are
reviewed and stopped.
• Education and training for practice staff –
utilise technician workforce to support.
• Consider paracetamol and/or topical
NSAIDs before oral NSAIDs, COX2
inhibitors or opioids.
• Provide patients advice on sick day rules
in every SMR
What changed as a result?
Reducing Risk Drugs that lower blood
pressure, or cause volume contraction,
might increase the risk of AKI by reducing
glomerular perfusion. These drugs include:
• Diuretics and SGLT2i which can
exacerbate hypovolaemia and
electrolyte disturbance.
• ACE inhibitors (ACEI) and Angiotensin
Receptor Blockers (ARBs), which reduce
systemic blood pressure and also cause
vasodilatation of the efferent arteriole.
• Other blood-pressure-lowering drugs,
which will lower systemic blood pressure
• Certain drugs may accumulate as a result
of reduced kidney function in AKI,
increasing the risks of adverse effects
e.g. Metformin which is associated with
an increased risk of lactic acidosis in high
risk patients.
• Patients taking Lithium are more likely to
reach toxic levels.
• Non-steroidal anti-inflammatory drugs
impair renal autoregulation by inhibiting
prostaglandin-mediated vasodilatation
of the afferent arteriole and may
increase the risk of AKI.
Polypharmacy applies to all patients in
every speciality!
Sarah Baig MRPharmS FMRPSI PgDip (Clin. Pharm) IPresc MSc PGCert FHEA
Pharmacy Professional Governance and Development Lead - Dudley Integrated Health NHS Trust
Assistant Professor and Prescribing Lead - School of Pharmacy, University of Birmingham
Background
Some medicines can contribute towards acute kidney
injury (AKI) when a person is dehydrated these include
Diuretics, ACE inhibitors and ARBs along with
Metformin, NSAIDs – e.g. ibuprofen, naproxen,
diuretics and SGLT2i. Often Type 2 diabetes and CKD
patients have polypharmacy and therefore
deprescribing can be beneficial in reducing tablet
burden and rationalising prescribing to minimise AKI.
References
1) National Kidney Foundation accessed April 2018 accessed 5 Drugs You May Need to Avoid or Adjust if You Have Kidney Disease |
National Kidney Foundation
2) Prevention and Management of AKI accessed April 2018 083(3)149.pdf (ums.ac.uk)