Polypharmacy can cause harm if it’s inappropriate

Introducing the first video in a series of 4 Medication Safety videos in 2020

Health care interventions, including medicines, are intended to benefit patients, but they can also cause harm. In 2019 WHO launched a report “Medication Safety in Polypharmacy” which states that ensuring medication safety in polypharmacy is one of the key challenges for patient safety today. Similarly, WHO Global Patient Safety Challenge – Medication Without Harm (2017) states that improvements in 4 areas 

  • Polypharmacy
  • Transitions of care
  • Therapy adherence and
  • Systems of care/digital prescribing 

could reduce harm from medication by 50% worldwide. 

In the full length video that we present to you today, Jana Lass, a clinical pharmacist from the University of Tartu in Estonia explains the key issues with Polypharmacy. Jana was joined by her peers who work together in the MOWG. This is the first in the series of 4 videos on medication safety presented to you by ECHAlliance, with support from MOIC.

Read more here

MOWG is a peer group chaired by Professor Mike Scott and made up of experts from across Europe who have come together to address these key issues and suggest solutions based on best practice.

The term polypharmacy is by definition a concurrent use of multiple medicines. It includes over-the-counter, prescription and complementary medicines. Polypharmacy is a consequence of the aging population. People live longer and more people suffer from multiple long-term conditions therefore needing more medicines.

 

However, it is also important to note that polypharmacy is often necessary and beneficial.

Polypharmacy is appropriate when

  • all medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient
  • therapeutic objectives are achieved or there is a reasonable chance they will be achieved in the future; 
  • medication therapy has been optimised to minimize the risk of adverse drug reactions and 
  • the patient is able and willing to take all of the selected medicines

Complex medical systems also create inappropriate polypharmacy, which is a stand-alone risk factor for morbidity and mortality.

 

Inappropriate polypharmacy could cause patient harm and decreased quality of life by increasing the risk of medication errors and adverse drug reactions as well as interactions between medications. As the number of prescribed medicines increases, also the risk from adverse effects increases. It also leads to significant waste of healthcare resources because of suboptimal patient concordance (patients not taking the prescribed medicines) to treatment plans.

Inappropriate polypharmacy occurs when

  • Medicines are prescribed by several care providers
  • Patients and health care professionals have different opinions regarding treatment options
  • Patients are using over the counter medicines for alleviating adverse effects caused by prescription medicines 
  • There are certain risk groups for inappropriate polypharmacy such as
  • Older patients because multimorbidity increases markedly with age
  • Residents in a care home setting 
  • Patients on high-risk medicines
  • Patients taking 10 or more medicines
  • Patients with co-morbidities
  • Palliative care patients

 

Examples of high-risk medicines are:

  • Opioids
  • Anticoagulants and antithrombotics (warfarin, DOACs, clopidogrel)
  • Hypnotics and anxiolytics (benzodiazepines and benzodiazepine-like drugs)
  • Drugs for rheumatological diseases (NSAIDs, corticosteroids, methotrexate)
  • Digoxin etc.

 

We can’t avoid polypharmacy but what can be done to make it appropriate?

Our goal should be to reduce inappropriate polypharmacy – irrational prescribing of too many medicines. This could be done by practising deprescribing which is a process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving treatment outcomes

 

 A whole systems approach should be adapted for polypharmacy management to: 

  • optimise the care of multimorbid patients
  • reduce the risks of inappropriate polypharmacy
  • maximise the benefits of the medications

 

The following practical tasks are suggested by the MOWG:

  • Medication review should be provided to vulnerable populations :
    • Medication reviews should be completed in primary and secondary care as well as at all transitions of care ideally by pharmacists but also by doctors and nurses
  • Development of multidisciplinary workforce 
  • Changes in the educational curriculum for health care professionals are needed and should ensure that:
    • Topics to develop necessary competencies and skills for addressing polypharmacy are included
  • Holistic, person-centred medication review is embedded in education and training for all healthcare professionals.
  • Raising patient awareness about the problems of polypharmacy and non-adherence:
    • Medical specialists need to empower patients to make more informed decisions about their treatment
    • Patients should be encouraged and supported by pharmacists to disclose all the medications they are taking
  • Greater interoperability of IT systems :
    • which identify patients taking multiple medicines,
    • with drug-interaction databases integrated in the prescribing tools
    • containing information on patients’ prescription medications in both primary and secondary care which are updated in real time.

 

To conclude; polypharmacy is a serious and significant public health challenge. Prevalence of polypharmacy is rising as the population ages and more people suffer from multiple long-term conditions. Countries should prioritise raising awareness of the problems associated with inappropriate polypharmacy. Health and social care organisations should address the issue of polypharmacy in their strategic plans. Physicians, nurses, pharmacists and other health care professionals combined knowledge is needed for polypharmacy management.

Polypharmacy and actions to identify and address the problems that it causes are everyone’s responsibility.

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AUTHORS:

Author and presenter:
Jana Lass, University of Tartu, Estonia
Co-Authors:
Professor Michael Scott, Medicines Optimisation Innovation Centre, Northern Ireland
Nana Veronica Beck, Region Syddanmark, Denmark
Dimitra Gennimata, Red Cross Hospital Athens, Greece
Nataša Jovanović Ljesković, Faculty of Pharmacy Novi Sad, Serbia
Fatma Karapinar, OLVG, Netherlands
Anna Nordström, Northern University Hospital Västerbotten, Sweden
Trine Ungermann Fredskild, Region Syddanmark, Denmark

PRESENTED BY:

Medicine Optimisation Working Group at European Connected Health Alliance
MOWG is chaired by:
Professor Michael Scott
ECHAlliance is chaired by:
Brian O’Connor

SUPPORTED BY:

MOIC Northern Ireland
MOIC is the only dedicated medicines optimisation centre in Europe. Working to deliver medicines optimisation for the people of Northern Ireland. 4 Star Reference Site status from the European Innovation Partnership on Active and Healthy Ageing

VIDEO PRODUCED BY:

Gregor Cuzak, coordinator of MOWG at ECHAlliance
Made by:
Superdot, Belgrade, Serbia
Copyright:
European Connected Health Alliance February 2020
References:
WHO Global Challenge technical documents for polypharmacy:

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