Re: Rationalising medications through deprescribing: The challenge of polypharmacy reviews
Tony Avery’s editorial on deprescribing (BMJ 2019;364:l570) highlights the challenges of deprescribing and polypharmacy review, particularly the complexity and consultation time.
A stop, sorted and special approach can help to focus a review. Medicines that that can or should be stopped and those that have already been sorted can generally be quickly identified. This leaves a much smaller group of medicines on which to focus the discussion.
STOP The obvious ones: person doesn’t like them, is not taking them, shouldn’t be ‘on repeat’ or the condition has
SORTED Medicines assessed and monitored within the last 12 months E.g. chronic disease clinics or hospital review,
and no outstanding concerns
SPECIAL Focus of the discussion: Person’s priorities, high-risk medicines, prescribing indicators (see below).
Many clinicians find a polypharmacy review challenging, however it is likely to be an important opportunity both for patients and for a sustainable NHS. There is no single way to undertake a review and recognising the following components can help clinicians to develop their own approach:
o Identify the common combinations and culprits 1,2,3,4
o Recognise multimorbidity, frailty and a person’s priorities 5,6
o Develop a personalised systematic approach (Scotland & Wales polypharmacy guides, No TEARS 7; Stop, sorted and special)
o Be flexible & prioritise
Focusing consultations in these ways, may help to identify a meaningful intervention
1. Pirmohamed M, Adverse drug reactions as cause of admission to hospital BMJ 2004;329:15
2. Stocks S J, Examining variations in prescribing safety in UK general practice BMJ 2015;351:h5501
3. Gallagher P et al., Screening Tool of Older Person's Prescriptions 2008 Int J Clin Pharmacol Ther. 46:72-83
4. Lewis T, Top ten prescribing errors, and how to avoid them Pulse 2015
5. Atul Gawande, Being Mortal
6. NICE NG56 Multimorbidity: clinical assessment and management
7. Lewis T, Using the NO TEARS tool for medication review BMJ 2004; 329:434
Competing interests: Author of: Using the NO TEARS tool for medication review BMJ 2004; 329:434 Top ten prescribing errors, and how to avoid them Pulse 2015