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Polypharmacy and medicines optimisation

Making it safe and sound


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    Martin Duerden

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    Tony Avery

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    Rupert Payne

Polypharmacy – the concurrent use of multiple medications by one individual – is an increasingly common phenomenon that demands attention at clinical policy and practice level. Driven by the growth of an ageing population and the rising prevalence of multi-morbidity, polypharmacy has previously been considered something to avoid. It is now recognised as having both positive and negative potential, depending on how medicines and care are managed.

This report proposes a pragmatic approach, offering the terms ‘appropriate’ and ‘problematic’ polypharmacy to help define when polypharmacy can be beneficial. Drawing on literature from predominantly Western countries, the report traces the occurrence of polypharmacy in primary and secondary care, and in care homes. It explores systems for managing polypharmacy and considers it in the context of multi-morbidity and older people, offering recommendations for improving care in both cases.

Key findings

  • For many people, appropriate polypharmacy will extend life expectancy and improve quality of life. Their medicines use will be optimised and prescribed according to best evidence.

  • In problematic polypharmacy there can be an increased risk of drug interactions and adverse drug reactions, together with impaired adherence to medication and quality of life for patients.

  • Many clinical trials and practice guidelines do not consider polypharmacy in the context of multi-morbidity. It is important that pragmatic clinical trials are conducted that include patients with multi-morbidity and polypharmacy.

  • Multi-morbidity and polypharmacy increase clinical workload, so doctors, nurses and pharmacists need to work coherently as a team with a balanced clinical skill-mix.

  • People often do not take medicines as they are intended. Evidence shows many dispensed medicines remain unused or are wasted.

  • During medication reviews, prescribers should consider if treatment should be stopped and ‘end-of-life’ care be offered for certain chronic conditions or cancer-related illness.

  • Patients with multi-morbidity could have all their long-term conditions reviewed in one visit by a clinical team responsible for co-ordinating their care.

  • Patients may struggle with complex drug regimens; their perspective on medicine-taking must be taken into account when prescribing.

Policy implications

  • More training is needed in managing complex multi-morbidity, polypharmacy and other aspects of medicines management, involving GPs, older care clinicians, orthogeriatricians, clinical pharmacologists, nurse specialists and clinical pharmacists.

  • Systems are needed that optimise medicines use where there is polypharmacy so that people gain maximum benefit from their medication with the least harm and waste.

  • There are numerous evidence-based guidelines for the treatment of single conditions, but there is a need for guidelines on the treatment of multi-morbidity.