The King’s Fund: Polypharmacy and Medicines Optimisation

Policy, medical training and clinical practice must adapt to the significant increase in patients taking multiple prescription drugs. That’s one of the key take-home messages from a report on polypharmacy published by The King’s Fund, that I co-authored with Martin Duerden (Bangor University) and Tony Avery (Nottingham University).

Polypharmacy is widespread, and associated with various adverse consequences, including prescribing errors, adverse drug reactions, impaired quality of life and considerable clinical workload. It is not a new issue but it is a growing one, driven by an ageing population, multimorbidity, and a focus on single disease frameworks. It is also an issue that remains poorly defined and understood. It’s particularly important to differentiate appropriate polypharmacy from problematic polypharmacy. With the former, multiple medicines may be prescribed entirely appropriately and according to good evidence. With the latter, medicines may be used inappropriately, or the intended benefit not be realised. Simple counts of drugs miss the full picture, but overly complex approaches lack practicality; we have proposed a pragmatic approach to identifying high-risk polypharmacy, based on combining simple counts of drugs with evidence of inappropriate prescribing.

There is a need to generate better evidence to support the use of multiple medicines. We require pragmatic clinical trials, which include participants with multimorbidity and polypharmacy, and clinical guidelines should take into account persons with multiple common co-morbidities – for example, a patient with COPD, diabetes and heart disease.
There are also implications for health services. Systems must be designed to manage patients with polypharmacy and multiple medical problems, yet so much of modern healthcare is based around single diseases. We need to enhance generalist services and improve coordination of care. General practitioners clearly have a fundamental role to play in this respect, but it is also important that we make best use of the expertise of clinical pharmacists and secondary care services such as Care of the Elderly physicians. The current trend towards ever-narrower specialism needs to be reversed, and education and training must address this.

Clinicians also need to become more aware of the importance of polypharmacy, and become better at managing it. Training is necessary to improve recognition of problematic polypharmacy and the strategies to reduce it. Doctors need to be empowered to stop medicines as well as starting them. We must ensure adequate time is available to see patients with these complex problems; 10-minute consultations and a medication review “tick box” are wholly inadequate. And of course the patient’s perspective must be considered, in terms of understanding, burden of care, adherence, and their wish (or otherwise) to pursue treatment of uncertain benefit.

Hopefully our report will help bring this important area to the attention of policy makers. Enhancing the management of polypharmacy has the potential to lead to improved and safer care for a substantial proportion of our population. There are certainly short-term implications with respect to increased workload, but hopefully this will fall in the longer term, with patients on simpler, rationalised medication regimens leading to more straightforward care and fewer adverse consequences. Some of the recommendations may take considerable time to implement, such as taking polypharmacy and multimorbidity into account in clinical trials and accommodating these issues in clinical guidelines. Other recommendations may take less time, depending on the political will to achieve change, such as building appropriately skilled multidisciplinary teams and improving relevant training for pharmacists and doctors. Finally, let us not forget there is a need for further research to support some of these suggestions; again, that will take time. Changing health policy is slow, but these issues are not going away. Let’s start acting now.

Polypharmacy and medicines optimisation: making it safe and sound by Martin Duerden, Tony Avery and Rupert Payne, is published by The Kings Fund and available free to download or to purchase for £10 at: The King’s Fund is an independent charity working to improve health and health care in England.

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