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CPD: Key Questions on polypharmacy and deprescribing

Key learning points

  • Probably the best way to identify and rationalise counter-productive polypharmacy is through an SMR 
  • Drugs commonly transferred onto repeat templates after discharge, and which might need to be stopped, include opioid analgesics, dual antiplatelets, hypnotics and PPIs 
  • ONS may be deprescribed when dietary intake is sufficient, weight has increased to target or the individual’s medical condition has resolved
  • In younger people with acute painful conditions without co-morbidities, the risk of GI bleed with NSAIDs is likely to be low – so a PPI may not be necessary 
  • In weighing up risk and benefit in the very elderly, bear in mind that statins are often well tolerated, but antihypertensives bring risks 

Dr Tony Avery is a GP and professor of primary care in Nottingham and Ojali Yusuff is a PCN pharmacist in Nottingham

Q: How can we recognise when appropriate clinical management by prevailing guidelines is developing into counter-productive polypharmacy?

Many of our clinical guidelines focus on the best evidence for managing specific conditions. When patients have multiple conditions, this can lead to polypharmacy, but polypharmacy is not always a bad thing. For example, in a patient with hypertension, type 2 diabetes and coronary heart disease, one of the main aims is to prevent or delay further cardiovascular events and the prescription of multiple medications (antiplatelets, antihypertensives and lipid-lowering therapy) work synergistically towards that aim. In other cases, patients have a range of disparate conditions that mean they can be in receipt of 10 or more medicines by following evidence-based guidelines. This is not necessarily a problem if the medicines appear to be working, the patient is willing to take them and there are no significant adverse effects. Nevertheless, when patients take multiple medicines for disparate conditions, we have little high-quality evidence of benefits and risks. Also, the likelihood of adverse effects increases, including drug-to-drug interactions, and patients will struggle to take their medicines as prescribed. 

Counterproductive polypharmacy can be identified by lack of concordance or low adherence to medication and also when patients present with symptoms that are likely to be adverse effects from the medicines they are taking. Nevertheless, this can sometimes be difficult to recognise, and there is a risk that a further prescription will be given to offset the unidentified side-effects of another drug (the so-called ‘therapeutic cascade’). Probably the best way of identifying counter-productive polypharmacy is through a structured medication review (SMR). 

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