Improve management of multiple medicine use, warns report

Policy, medical training and clinical practice have failed to adapt to a significant increase in the number of patients taking multiple prescription drugs, according to a new report on polypharmacy and medicines optimisation, published by The King’s Fund.

Estimates suggest that from 1995 to 2010 the number of patients taking ten or more medicines trebled, reflecting a large increase in the number of people with complex, or several, long-term conditions –  largely driven by an ageing and increasingly frail population, but also by increasing use of multiple interventions. While, in the past, taking numerous prescription drugs (polypharmacy) has often been seen as something to be avoided, the report shows that taking an evidence-based approach to polypharmacy should improve outcomes for many people.

However, with most research and health systems based on single-disease frameworks, policy, medical training and clinical practice have often not adapted to provide ‘appropriate polypharmacy’ – optimising the use of multiple medicines and prescribing them according to best evidence. Our report suggests that for polypharmacy to be used more effectively there needs to be:

• better training for doctors in managing complex multi-morbidity and in polypharmacy
• more research set in the context of using treatments where people have several diseases, rather than selecting subjects who have single conditions
• national guidelines for multi-morbidity to match those for single conditions
• improved systems, particularly for GPs, to flag problematic polypharmacy
• regular reviews of patients’ medication and a willingness to consider stopping medication, particularly in cases of limited life expectancy
• changes in systems of medical care to move away from increased specialisation towards a focus on multi-morbidity.

The report argues that polypharmacy needs to be better understood and defined, and accompanied by more engagement with patients to ensure that medicines are taken in the way that prescribers intend. This may require compromise between prescribers and patients to ensure that patients feel confident in what they are taking and situations where medicines go unused or are wasted are avoided.

Integrated care is now widely accepted as the way forward in caring for people living with multiple, complex, long-term conditions. Appropriate polypharmacy, or medicines optimisation, now needs to be similarly accepted as one of the ways in which we can deliver more co-ordinated care.

Martin Duerden, the report’s lead author, said: ‘Currently patients may still be treated in silos where one specialist doctor will look after their care for diabetes, another for their heart condition and a third for their asthma. They will then be prescribed medicines for each condition but these are often not considered in the whole. We need more generalist doctors able to understand a patient’s medicine intake in its entirety and how they are managing, especially if they have to take numerous medicines at different times in the day.’

He added: ‘A sensible way forward might be to identify those taking ten or more medicines and focus on them first. Their medicine intake should be regularly reviewed so that as well as the option of adding a medicine as a condition worsens, they can also scale back or even stop treatment – particularly recognising that end-of-life quality applies to chronic conditions as well as cancer.’

• Read the report: Polypharmacy and medicines optimisation
• See Duncan Hockey's blog: Carry on prescribing: who is responsible for co-ordinating patients’ medication?