Polypharmacy: a necessary evil

The trouble is, faced with a patient who has 10-15 medications prescribed, one cannot know whether: a) someone has spent a lot of time, thought, and discussion with the patient in coming to the best combination of treatments, or b) a variety of doctors have relatively randomly added to the list for a variety of justifiable (or not) reasons.

Without an audit trail of who decided what, for what reasons, and when, any doctor encountering a patient for the first time cannot know how much to interfere.

Two key factors operate here:

1. With increased - and increasing - fragmentation of health care in the NHS, being able to ascertain the provenance of any prescribing decision is increasingly difficult.

2. The proliferation of guidelines (often based on evidence irrelevant to frail (or very old) patients has led to an explosion of prescribing for conditions, often despite the relevance to the frail individual with multiple pathologies.1

This double product, with no-one ultimately specifically responsible for the patient overall, as opposed to the individual pathologies, epitomises the challenge.

Primary care colleagues are in a bind, as other responses have identified. They are required to prescribe drugs for QOF payments (almost irrespective of relevance).2 They cannot know whether medications prescribed in secondary care have been done so after due deliberation by an experienced clinician, reflexly by an inexperienced F1 slavishly implementing a hospital guideline, or by a passing specialist focusing exclusively on a specific diagnosis.

I hope that bringing together knowledge of the various conditions and their potential treatments, knowledge of the relevant pharmacology, and the value systems and preferences of the key person in all this - the patient - does not become a challenge too far for the current infrastructure and resources.

Sadly, I am not that confident, but having a universal standard of an audit trail of who prescribed what, when, and why (wwww) for any medication would be a good start.

Reference
1. Mangin D, Heath I, Jamoulle M. Beyond diagnosis: rising to the multimorbidity challenge. BMJ : British Medical Journal. 2012 Jun;344. Available from: http://dx.doi.org/10.1136/bmj.e3526

2. Byatt K. Overenthusiastic stroke risk factor modification in the over-80s: are we being disingenuous to ourselves, and to our oldest patients? Evidence Based Medicine [in press]

'As anaesthetists we intentionally and routinely subject our patients to acute polypharmacy (even a simple general anaesthetic may result in exposure to more than a dozen drugs) in an attempt to provide them with what many would consider the ultimate necessary evil - general anaesthesia: 'painless surgery' is also of course for many the ultimate blessing.

Accurate knowledge of what medicines are being taken (including, pharmacy, herbal & social remedies) together with a good understanding of underlying morbidities & risks, is fundamental to provision of high quality anaesthesia care. We to a large extent, act as the patient's general medical specialist during their surgical care episode.

We spend much more than a few minutes (sometimes many hours) with our patients and furthermore see how they respond to the anaesthesia/surgery 'stress test'. We come to know (and think) a lot about them, but all too rarely communicate any of this information back to the general practitioner: 'what goes on during oblivion - stays in oblivion!'

Whilst it would wrong be pretend that we could or should take on the role of critically assessing and optimising chronic medication for our patients, it may be that we are in a good position to highlight areas that might warrant further review in general practice - including over- and under-treatment, side effects, interactions & compliance issues.

As anaesthetists we should perhaps consider that handover (continuity) of care involves not only hospital colleagues supervising recovery, but also those in primary care overseeing, promoting and encouraging return to health.'

Better teamworking - better polypharmacy.

The big and worthy King’s Fund report discussed by Jaqui Wise covers a lot of ground, but its focus is blurred and it misses some core points. It would take years to implement the sensible changes proposed in managing multi-morbidity and in prescribing in care homes.

The authors do not say what they think should be done NOW.

A remarkable and baffling omission concerns the role of the patient. Patients (and some professionals) do not understand the practical difficulties and dangers caused by polypharmacy. Those using three or more different medicines need a crash course. They need to be able to recognise generic names, to use the drugs well and to work well with the doctor, pharmacist and nurse – who need to teach and to be supported in teaching. As Michael Balint reminded us, ’doctor’ originally meant ‘teacher’, and teaching is needed now more than ever though few value it.

PATIENTS must learn to understand
(1) the difference between preventive treatment, as with statins, and medication for existing problems
(2) what the benefit/ harm balance means to them personally, how it is related to dosage, and how it can change over time. This is what lies behind the endless and fruitless discussion of ‘adherence’.
(3) that medicines may interact
(4) their own role in contributing actively to follow-up, noting and reporting the apparent effects – expected and unexpected – during and after use of a medicine.

PRESCRIBERS of potentially long-term medication must make it a habit to explain at the start when and how the decision will be made to change it or to stop.

These omissions seem not to concern the King’s Fund chief executive. He says that ‘the paper makes clear that action is needed on several fronts, and must involve patients, doctors, nurses and pharmacists’. This was known long ago. The report missed its opportunity to create an authoritative blueprint for such action and the King’s Fund has missed its opportunity to lead the way.

I think it is very important to raise awareness amongst junior doctors about the issues associated with polypharmacy. Often as medical students we learn how to prescribe on drug charts but underestimate the importance of questioning the rationale for every medication on there.

When clerking patients on hospital admission, we expect their past medical history to explain their current medications. Often however, patients will be taking various medications for which they have no explanation. They may have stopped taking medications without being instructed to do so or they may be taking over the counter medications without realising harmful interactions. It is very important to elucidate this information.

It is easy for us to add medications to treat new symptoms but we even more importantly need to recognise medications that are not necessary or may even be causing harm through interactions.

Drugs that we have started in hospital should be reviewed daily, by the whole multidisciplinary team and not only pharmacists to avoid sending patients home on unnecessary medications. Additionally we should remind ourselves when writing discharge summaries that we check every medication on there is indicated. For example not all patients need to go home with regular pain relief such as NSAIDS, which could potentially result in an upper GI bleed. Not all patients need to be sent home on regular laxatives, only to present to their GP or hospital with diarrhoea.

Some medications started in hospital may need dose reviews in the community. This can easily be missed if this information is not clearly conveyed to the GP and family/carers looking after the patient. Those writing discharge summaries should ensure they include clear instructions regarding medication review.

Importantly, patients should be educated about their medications, if they have capacity, prior to hospital discharge to avoid the issues associated with polypharmacy.

It is a great idea to have electronic discharge summaries that include the indications for every medication and one which could help resolve the issue of unnecessary polypharmacy. It will not only serve as an explanation aid for patients but also convey important information to other healthcare professionals looking after the patient. This may be of particular importance for patients who are frequently in and out of hospital and are regularly having medications changed.