Medicines can provide many benefits to treat and prevent health problems but they come with risks. Medicines that were once helpful when first prescribed, may no longer be helpful or become unsafe.1
GPs are faced with an ageing population, increasing comorbidities and treatment options. As specialised co-ordinators of patient care they have a unique and important (but admittedly challenging) role in an increasingly complex health system. Despite these obstacles they provide skilled and compassionate care that prevents disease and promotes health. Assessing cumulative medicine risk is an important role for GPs that can improve health outcomes for their patients.
The greatest predictor of medicine adverse effects occurring is the number of medicines taken.
More than half the people over 65 on multiple medicines are taking at least one potentially inappropriate medicine.2 25% of patients who are on multiple medicines have adverse effects (AEs) directly attributable to one or more medicines. Certain medicines are considered higher risk e.g. anticholinergics, antipsychotics, diuretics, antidepressants, opioids and non-steroidal anti-inflammatory drugs (NSAIDS).3 The risk increases if any of the high risk medicines are taken together.
Deprescribing is a patient-centred and systematic process to taper, reduce or stop4 the use of potentially inappropriate medicines for people who take multiple medicines. A Medicines Review is a practical way to start this process.
Older adults are often more sensitive to medicines and disproportionately experience medicine-related harms.6 Their altered physiology (relative to younger adults) changes the way medicines are metabolised and excreted, most importantly reduced renal and hepatic function, which increases the risk of AEs.7 At the time of an accredited pharmacist-led Medicines Review, up to a quarter of older people are experiencing adverse effects of their medicines and on average four medicine related problems are detected.8, 9
Factors contributing to polypharmacy includes:
Talk to your patient about what is important to them - shared decision making is central to successful deprescribing.17 Explain that medicines are always worth reviewing especially as circumstances change. Patients tend to have a high level of trust in their GP and are usually happy to have a conversation about their medicines.18
Ask your patient what they understand about their medicines and how they are managing them.
Talk about potential adverse effects. Patients may be experiencing symptoms that could relate to their medicines without realising it.
Reassure your patient that in many cases they could safely reduce or stop a medicine. In some cases non-drug approaches could be safer and more effective e.g. psychological approaches for insomnia or physical therapy for musculoskeletal pain. Allied health services are available through the Department of Veterans' Affairs (DVA) for all Gold Card holders, White Card holders for accepted conditions, or for all via Medicare’s chronic disease management items.
Deprescribing can be beneficial and is unlikely to cause harm.12
GPs are ideally suited to start a conversation with patients about their medicines and, if there is good reason, to consider trialling a reduced dose or ceasing altogether.
The following stepwise approach may help (adapted from Reeve et al (2014),19 Scottish polypharmacy guidelines 20183 and Primary Health Tasmania15).
The patient is central in any Medicines Review process – engage with them and explain that you want to talk about all their medicines. Reassure them that you will provide support during the process. Gather all relevant information about their medicines including ones they take regularly, as needed and any over the counter products including complementary medicines.10, 20 Are they having any problems taking any of their medicines?
Establish treatment objectives together. What is important to the person at this time? Discuss indications, benefits and potential harms. This can help patients understand the trade-off between potential benefit and adverse effects and help clarify their values, priorities and preferences.
i Identify the necessary or appropriate medicines on the list.
Medicines that if stopped would cause serious withdrawal symptoms or worsen existing clinical issues, e.g. medicines for epilepsy or arrhythmias.
ii Identify unnecessary or inappropriate medicines on the list.
Are there ineffective medicines? Does the medicine cause more harm than benefit? Was it only ever for a short-term indication? Has the potential benefit been reduced due to changes in the patient’s situation and limited life expectancy e.g. statins or antihypertensives.
iii Consider if any of the patient’s medicines are causing adverse effects.
The risk of adverse effects may accumulate over time, some of these effects may be obvious, others more subtle and not recognised. Some may be mistaken as symptoms of chronic disease or ageing.21 Always ask if there are any symptoms that are bothering your patient.
Use the cumulative risk tool
Does the patient and/or carer understand what you have discussed? Make sure the decisions made are in line with patient preferences. Provide specific withdrawal plans including tapering schedules if abruptly ceasing medicines could result in rebound symptoms or withdrawal reactions (e.g. PPI, antidepressant, opioid, benzodiazepines). Communicate plans to nursing staff if in an aged care setting. If the patient is hesitant you may need to negotiate a rate of reduction with which they are comfortable.
Monitor for withdrawal reactions. Provide specific supports (pharmacological and non-pharmacological) and action plans to manage symptoms which may worsen as a result of treatment withdrawal. Offer support and follow up. For some patients weekly reviews may be appropriate until they feel more confident.
The GP’s experience, clinical judgement, knowledge of the patient and their circumstances is essential in tailoring advice, and identifying other additional medication related problems.
This tool has been developed and adapted from the Scottish polypharmacy guidelines3 2018 and can also be used to see how adjustments to your patients medicines might reduce their risk of cumulative adverse effects.
The simplest intervention to organise and, arguably most beneficial to the patient, is to organise a Home Medicines Review (HMR) or Residential Medication Management Review (RMMR) with an accredited pharmacist (see Medicare benefit items 900 and 903 www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=900&qt=item). These are structured evaluations of a patient’s medication list that improve the patient’s understanding of their medicines, optimise their medicine use and help prevent medication-related problems.
Medicine reviews may improve compliance and reduce:22
The patient’s home is the preferred location for an HMR. However, in response to the COVID-19 pandemic, HMRs may occur via telehealth where a patient meets the eligibility criteria (aged over 70, has a chronic health condition or is immunocompromised).
A ‘patient centred’ deprescribing process usually generates a significant amount of information to share with an accredited pharmacist. Referral should list the patient’s clinical conditions, medicines (including those that you think may be ceased) and any specific areas of concern, for instance, physical symptoms that you think are linked with medicines. After the initial interview, the accredited pharmacist produces an HMR Report that outlines their findings. The report aims to improve the referrer’s understanding of how the patient is using their medicines, and make recommendations that help the referrer and patient develop a medication management plan.
Share the report with the patient, carers and other relevant members of the health care team, such as nurses in aged care facilities or other community settings as well as the response you have provided to the pharmacist.https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=900&qt=item)
Take home messages
For you, the GP
Consider the risk of cumulative medicine load, assess potential adverse effects, and refer for an HMR or RMMR.
For your patients
Ask them to think about the medicines they are taking. Do they understand what they are all for? Have any symptoms been bothering them? What are their treatment preferences and overall goals of care?
Empowering patients to ask questions will help them feel more confident about their medication management and lead to better health outcomes.23
For the pharmacist
When doing a Medicines Review ask about symptoms using a structured ‘body systems’ approach. Inquiring about symptoms regardless of their origin is important as patients do not always recognise drug-associated symptoms as such.
For those working in an aged care setting
Liaise with the patient and their family about any possible adverse effects, elicit preferences about medicines, and co-ordinate care with GP and pharmacist. Encourage referral for a RMMR.
Guidelines to reduce and cease specific classes of medicines: www.primaryhealthtas.com.au/resources/deprescribing-resources/
An electronic medicines decision support system which includes the Drug Burden Index (DBI): www.nps.org.au/professionals/anticholinergic-burden/clinical-resources-and-tools/
Deprescribing resources, information for the public and professionals: www.australiandeprescribingnetwork.com.au/
RACGP aged care clinical guide (Silver Book) 5th ED Part A Deprescribing, 2019: www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/silver-book/part-a/deprescribing/
Scottish guidance provides a 7 step framework to assess medicines and guide to deprescribing (the World Health Organization have adopted a similar approach in its Global Patient Safety Challenge): www.therapeutics.scot.nhs.uk/polypharmacy/
Canadian resource for patients, the public and health professionals which includes practical videos for clinicians to improve patient engagement: www.deprescribingnetwork.ca/
Another Canadian resource from the Bruyere research institute with resources for patients and clinicians: www.deprescribing.org/
For deprescribing in specific clinical situations
Cognitive decline: cdpc.sydney.edu.au/research/medication-management/deprescribing-guidelines/
Palliative care: www.palliaged.com.au/tabid/4432/Default.aspx
78 year old veteran with multiple comorbidities including ischaemic heart disease (IHD) (coronary artery stenting some years ago), hypertension (last office BP was 118/75), atrial fibrillation (AF), gastro-oesophageal reflux disease (GORD). He has chronic low back and neck pain, depression and is overweight.
He has been feeling more dizzy and nauseated recently, and has noticed ankle swelling. His wife has seen more bruising on his forearms, and feels he has worsening cognitive decline, is becoming more unsteady on his feet and is feeling less safe in the car when he drives.
He has a usual GP and a cardiologist and is awaiting geriatrician review.
He reports taking fish oil for joint pain as he believes it may be ‘good for that as well as his heart health and memory’. He has not had any recent episodes of chest pain and has not used his GTN spray for years.
His Mini Mental State Examination (MMSE) is 23/30. BP measures in clinic today suggest a postural drop; 123/79 sitting and 112/70 standing.
You have decided to refer for an HMR but want to do a full assessment first by following a stepwise process to help guide your referral to the pharmacist.