Polypharmacy prescribing guidance - draft: consultation

1. Clinical foreword

The care of people with multimorbidity is one of the greatest challenges now faced by the health service. ^[1] Care of adults with multiple medical conditions is often overly complex and rarely person-centred. This leads to poor health outcomes, unsustainable levels of expenditure and avoidable environmental damage, all of which disproportionately affects the most vulnerable in society. Medication is the single most common healthcare intervention and generates the third highest cost of health expenditure. [2] A core element of care is the management of multiple medications (usually to manage multiple morbidity), known as polypharmacy.

There is a need to address polypharmacy management as a public health issue. Multimorbidity does not just affect the older adult. For example, 29% of people with multimorbidity are under the age of 65 years, and disproportionally come from the most deprived communities. [3] The vast majority of medical research, guidelines and contractual agreements have focussed on single targets for single disease states, whereas in reality most people have multimorbidities, requiring multiple treatments.³

The resulting polypharmacy (use of multiple medicines) can be appropriate or inappropriate. Polypharmacy becomes inappropriate when the medication risks begin to outweigh the benefits for an individual, and this is the important area to consider rather than the number of medicines an individual is taking alone. The aim of addressing this is to identify those at greatest risk of harm and to agree a medication regimen that is tailored to their changing needs and expectations, so that the use of medicines is safe and person-centred. Although research in this area is limited, this guidance is based on best evidence to date from a review of current literature and has been developed to support both individuals and healthcare providers.

An important principle in improving the care of those with multimorbidity is to ensure an integrated care approach to health and social care services.^[4] This can help address medication systems, processes and procedures that support improved outcomes for people by helping reduce errors that result from disjointed ways of working.

Since the publication of Choosing Wisely, key policy documents, including Realistic Medicine; value based health and care and Prudent Healthcare have raised awareness of using resources wisely, and the importance of the individual’s involvement in decision-making about their healthcare.

We are delighted to present the fourth edition of Polypharmacy Guidance: Appropriate Prescribing - Making medicines safe, effective and sustainable 2025-2028 which aims to provide guidance on preventing inappropriate polypharmacy at every stage of the person’s journey. The 7-Steps process is a clear structure for both the initiation of new and the review of existing treatments, which places a greater emphasis on ‘what matters to the individual?’ The Drug Efficacy (NNT) tables have been further refined and provide the relative clinical efficacy of common interventions. Harm reduction can be targeted through the use of the Cumulative Toxicity and Anticholinergic Burden guidance. Both have been updated and the former of which has been revised and updated through a modified Delphi (clinical consensus) approach. Addressing inappropriate polypharmacy contributes to addressing the climate and sustainability strategy by both reducing the waste from the number of medicines unnecessarily prescribed and the reduction in carbon footprint from hospital admissions or primary care contacts due to medication related harm.

The extensive set of National Polypharmacy Indicators have been further developed and prioritised by a clinical consensus approach. These support national progress and aid prioritisation of individuals for review. Alongside this, standardised Case Finding indicators have been incorporated into clinical decision support tools in GP IT systems that have Medicines and Healthcare products Regulatory Agency (MHRA) approval, to facilitate improvement and support clinical outcome monitoring. These can be found within the Scottish Therapeutics Utility (STU).

The person-centred Manage Medicines app, which supports individuals, their families and carers in shared decision-making about their medicines, has been developed further and now contains PROMs (patient reported outcome measures). This allows the individual to prepare for these conversations by considering “what matters to me”. To support this there is also development of adherence visualisation.

The importance of polypharmacy management is now recognised internationally. The WHO Third Global Patient Safety Challenge, Medication without Harm, has included the appropriate management of polypharmacy as a key flagship area to address.[5] The aim is to reduce severe avoidable medication related harm globally by 50% over five years. Work from Scotland and the SIMPATHY project have informed the WHO key documents: Medication Safety in Polypharmacy and Medication Safety in High-Risk Situations. [6]^, [7] A recent systematic review found that the prevalence of medication related harm globally is 1 in 20, where one fourth of the harm was potentially serious or life threatening. The majority of harm, 53%, occurs at the ordering/ prescribing stage and 36% at the monitoring/ reporting stage, with 80% of the avoidable harm arising ordering/ prescribing stage. [8]

This polypharmacy guidance also addresses the use of high-risk medicines and ensures that information on appropriateness of medicines is shared across transitions of care. Building on the existing work in Scotland and SIMPATHY,2 the iSIMPATHY project implemented the model for scale up and delivery across three European countries. ^[9] iSIMPATHY carried out reviews in different settings including hospital in-patient, out-patient and GP practice settings. A total of 6,481 patients participated in iSIMPATHY medicines reviews. The average age of patients reviewed was 72 years and 53% were female. An average of six long-term conditions were recorded per patient, with an average of 11 interventions per review. These included patient education, medicines reconciliation, medication changes and monitoring. Key benefits were obtained by utilising the 7-Steps approach. The factors that will support implementation are highlighted in the guidance.2 This has been highlighted as the blueprint to address medication use in the recent Chief Medical Officer for Scotland report.

Interventions made were graded for clinical significance, with 82% being classified as clinically significant and 968 (4%) potentially preventing major organ failure, adverse drug reactions or incidents of similar clinical importance. Recommended interventions were accepted in 94% of interventions. The average number of medications reduced from 12 to 11, with 92% of the reviews resulting in more appropriate medication use, therefore decreasing the likelihood of medication-related harm. Inappropriate medications were stopped (i.e. deprescribed), reduced or altered to improve appropriateness.

With the publication of Polypharmacy Guidance: Appropriate Prescribing - Making medicines safe, effective and sustainable 2025-2028, and supported by Realistic Medicine and Value Based Health and Care, the requirement now is that NHS Boards will build on the foundational work of the last five years and focus resource on accelerating the capacity of polypharmacy reviews to further increase the benefit to individuals.

Alpana Mair Head of Effective Prescribing and Therapeutics

Prof. Sir Gregor Smith Chief Medical Officer

Alison Strath Chief Pharmaceutical Officer

Anne Armstrong Interim Chief Nursing Officer