Polypharmacy prescribing guidance - draft: consultation

2. Executive Summary

Caring for people with multimorbidities and polypharmacy is an increasing global challenge. Across the European Union (EU), up to 18% of unplanned hospital admissions are attributable to harm from medicines, and over 70% of these are in the older person on multiple medicines. [10]^,[11] There are significant opportunities to reduce this burden by timely and effective interventions. 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.8 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 at the prescribing stage.8

The case for effective polypharmacy management is clear. However, in a complex healthcare setting with many competing priorities it is useful to outline the quality, economic, environmental and sustainability reasons why it should be prioritised. A holistic polypharmacy review has the potential to address all six dimensions of quality: efficacy, safety, efficiency, timely, equity and acceptability.^[12] Discussion of the relative clinical effectiveness of commonly used medicines (e.g. Drug Efficacy (NNT) table) or identifying safety issues (e.g. cumulative toxicity and anticholinergic burden), can help empower individuals, families and their carers to be actively involved and engaged with their treatment and care decisions. A holistic polypharmacy review will often result in an element of deprescribing, but stopping medicines should not be the primary driver. This updated guidance provides information on areas to consider when conducting a person-centred medication review, in particular the support for the individual to have an active role in shared decision-making. This combined with the knowledge and experience of the prescriber will help to ensure that treatment plans are person-centred to achieve the preferred outcomes.

We all have a role to play in driving better management of polypharmacy, whether, clinical, academic, policy maker or as an individual patient.

The European Union (EU) funded project SIMPATHY2 studied polypharmacy management in Europe, and has identified six key recommendations to improve medication safety, of which polypharmacy is an essential element:

1. Use a systems approach that has multidisciplinary clinical and policy leadership

2. Nurture a culture that encourages and prioritises the safety and quality of prescribing

3. Ensure that patients are integral to the decisions made about their medicines and are empowered and supported to do so

4. Use data to drive change and measure outcomes

5. Adopt an evidence-based approach with a bias towards action

6. Utilise, develop and share tools to support implementation

Between 2020 and 2023, together with Northern Ireland and Ireland, Scotland led implementation of the key recommendations using the 7-Steps medication review process, in the further EU funded work, iSIMPATHY.9 Lessons learnt from SIMPATHY, iSIMPATHY and the continuous improvement of polypharmacy management in Scotland have helped to shape this Polypharmacy Guidance: Appropriate Prescribing Making medicines safe, effective and sustainable 2025-2028. The iSIMPATHY project 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 which included patient education, medicines reconciliation, medication changes and monitoring. Key benefits were obtained by utilising the 7-Steps approach.

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. Training has been developed to support the wider multidisciplinary team undertake these reviews in practice. The training is hosted by NES on TURAS and has CPD accreditation from RCP UK.

In Scotland, iSIMPATHY was run across all healthcare settings, primary secondary and outpatient settings. Polypharmacy reviews should be done in all healthcare settings and recent education tool by Royal College of Physicians UK provides a toolkit for the use of the 7-Steps in the acute setting.^[13]

Greater emphasis has been placed on shared decision-making to actively engage the individual with the 7-Steps medication review, and development of Patient Reported Outcome Measures (PROMs). This allows the individual to be an active participant in shared decision-making. The Drug Efficacy (NNT) tables help discussion with the individual regarding the relative potential benefits of a range of common therapeutic interventions. The extensive set of National Polypharmacy Indicators have been further developed and prioritised by a clinical consensus approach, to support national progress and to prioritise individuals for review to understand prevalence and monitor Clinical Outcomes.

Alongside this, Polypharmacy Case Finding Indicators have been further refined through consensus to identify those at increased risk of medication related harm. These have been incorporated into computerised clinical decision support, approved by the MHRA, and will help prescribers to address medication safety issues when reviewing an individual’s medical records.

The Medication Sick Day Guidance has been updated to include new agents, such as those used in the management of diabetes that can cause harm and modified to allow individuals and healthcare professionals to highlight medications that may need to be withheld during episodes of acute dehydrating illness to reduce the risk of acute kidney injury.

Resources have been made available electronically, e.g. through integration with the GP clinical systems and revised ManageMeds polypharmacy app which supports people in shared decision-making about their medicines.

The hot topics and case studies in the guideline have been expanded to include therapeutic areas that provide challenge when considering inappropriate polypharmacy in the context of multimorbidity, and harm caused by medication such as frailty, and chronic pain. The case studies reflect the clinical complexity commonly faced in practice and can be used as educational tools to support a consistent person-centred approach to undertake the reviews.

The challenge of safe polypharmacy in long-term condition management, in the context of increasing burden of non-communicable disease, is gaining international attention. The WHO Third Global Patient Safety Challenge, Medication without Harm, has included the appropriate management of polypharmacy as a key flagship area to address. This guidance has influenced and drawn on the Medication Safety in Polypharmacy: Technical Report and the Medication Safety in High-Risk Situations report.6^,7