Appropriate Long Term Prescribing and Polypharmacy

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Appropriate Long Term Prescribing and Polypharmacy

• Alpana Mair
• Dr Gregor Smith

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Some Background The ageing population

• 62 projected rise in over 65s 2006-31
• 144 projected rise in over 85s 2006-31
• Increased prevalence of LTC, esp COPD and
  Diabetes
• 24 projected rise in older people admitted as
  emergencies by 2016
• Would require an extra 3.5 billion 2031

Audit Scotland
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Multiple Morbidities

• Multiple conditions presence of 2 or more LTC
• Largely the norm but associated with poorer
  outcomes
• More people in Scotland with MM below 65 years
  than above
• Develops around 10 years earlier in deprived
  areas
• Associated with more medical errors

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Multimorbidity in Scotland
Mercer, Guthrie, Wyke Scottish School of Primary
Care
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Most people with any long term condition have
multiple conditions in Scotland
Mercer, Guthrie, Wyke Scottish School of Primary
Care
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Mercer, Guthrie, Wyke Scottish School of Primary
Care
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Pr. Bruce Guthrie, Dundee
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Pr. Bruce Guthrie, Dundee
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Contributory Factors

• AGE
• Non age factors that contribute to developing
  polypharmacy include
• Multiple morbidities
• Residence in long term care home
• Hospitalisation, esp repeat episodes of care
• Patient expectation
• GP attitude
• Consultation with several doctors

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Polypharmacy associated dangers

• Adverse drug event
• Confusion
• Falls
• Interactions
• Drug drug Interaction
• Drug Disease Interaction
• Poor compliance and concordance

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Drugs commonly associated with admissions due to
ADR

• NSAIDs 29.6
• Diuretics 27.3
• Warfarin 10.5
• ACE 7.7
• Antidepressants 7.1
• Beta blockers 6.8
• Opiates 6.0
• Digoxin 2.9
• Prednisolone 2.5
• Clopidogrel 2.4

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High Risk Combinations

• NSAID plus any of
• ACE or ARB diuretic (triple whammy)
• eGFR lt60
• Diagnosis heart failure
• Warfarin
• Age gt75 without PPI

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High Risk Combinations

• Warfarin Plus any of
• Another antiplatelet
• NSAID
• Macrolide
• Quinolone
• Metronidazole
• Azole antifungal

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High Risk Combinations

• Heart Failure diagnosis plus any of
• Glitazone
• NSAID
• Tricyclic antidepressant

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Drugs Poorly Tolerated in the Elderly

• Digoxin (doses higher than 250mcg)
• Antipsychotics
• Tricyclic antidepressants
• Benzodiazepines
• Anti cholinergics
• Phenothiazines
• Combination painkillers

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Special considerations

• Orthostatic hypotension
• Shared side effects eg sedation, bleeding
• Diabetic treatment optimal HbA1c
• Antipsychotic medication
• Laxatives
• Shortened life expectancy

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Drugs which can be associated with rapid
symptomatic decline if stopped

• ACE inhibitors in heart failure / LVSD
• Diuretics in heart failure
• Steroids
• Drugs for heart rate or rhythm control
• Anticonvulsants for epilepsy
• Antidepressant, antipsychotic, mood stabilisers
• amiodarone
• Drugs for managing Parkinsons Dis
• Disease modifying anti-rheumatic drugs

With caution
With specialist advice
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CEL 36 November 2012

• Appropriateness of long term prescribing
• At medicines review
• On starting new medicines
• First iteration of National Guidance
• Aim to improve therapeutic care by reducing the
  risk of adverse drug reactions associated with
  polypharmacy

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GMS Contract 2013 / 14

• Unique negotiated settlement in Scotland
• QPQOF High Risk Patients
• Anticipatory Care Plans
• Polypharmacy Review
• Multi-disciplinary approach
• SPARRA risk score 40-60
• 0.75 practice popn 1st yr, rising to 1.5 2nd yr

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Questions?

• Dr Gregor Smith
• Alpana Mair