3rd Edition, 2018 - therapeutics.scot.nhs.uk

1 3rd Edition, 2018 2 If using any content from this document, please acknowledge the Scottish Government Polypharmacy Model of Care Group, 2018. When referencing this document, please use the following format: Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3rd Edition, 2018. Scottish Government Cover images courtesy of jk1991 at Infographics courtesy of SIMPATHY consortium Key words and search terms: polypharmacy, appropriate polypharmacy, inappropriate polypharmacy, deprescribing, 7-Steps, Drug Efficacy (NNT), Anticholinergic Burden, Cumulative Toxicity, Polypharmacy Indicators, Case Finding Indicators, Outcomes Indicators 3 4 Foreword The care of patients with multi-morbidities (multiple medical conditions) is the greatest challenge now faced by the health service, as it can create overly complex health care for some of the most vulnerable in society.

2 The vast majority of medical research, guidelines and contractual agreements have focussed on single targets for single disease states, whereas in reality most patients have multi-morbidities, requiring multiple The resulting polypharmacy (use of multiple medicines) can be appropriate or inappropriate and the key healthcare aim for the individual patient is to ensure the safe and effective use of their multiple medicines. Despite research into this area being in relative infancy there exists a requirement to produce guidance for both patients and healthcare providers, based on the best evidence to date. Polypharmacy becomes inappropriate when the medication risks begin to outweigh benefits for an individual patient.

3 The aim of addressing this is to identify those patients at greatest risk of harm and to agree a medication regimen that is tailored to their changing needs and expectations. An important principle in improving the care of patients with multi-morbidities is to ensure minimised fragmentation of health and social services through improved integrated care, which can help address medication systems, processes and procedures that are flawed or dysfunctional. In addition, there is a need to address polypharmacy management as a public health issue, as multi-morbidities do not just affect the elderly. For example, 29% of people with multi-morbidities are under the age of 65 years of age, and come from the most deprived Since the publication of Choosing Wisely, key policy documents, including Realistic Medicine and Prudent Healthcare, have raised awareness of using resources wisely and the importance of the patient s involvement in decision making about their healthcare.

4 We are delighted to present the third edition of Polypharmacy Guidance, Realistic Prescribing 2018, which aims to provide guidance on preventing inappropriate polypharmacy at every stage of the patient journey. The 7-Steps is a clear structure for both the initiation of new and the review of existing treatments, which has been updated to place a greater emphasis on what matters to the patient ? The Drug Efficacy (NNT) tables have been refined and provide the relative clinical efficacy of common interventions, for the patient. Harm reduction can be targeted through the use of the Cumulative Toxicity and Anticholinergic Burden tools.

5 An extensive set of Polypharmacy Indicators have been developed and prioritised by a clinical consensus approach, in order to standardise Case Finding, understand prevalence, and provide Clinical Outcomes monitoring. We are also excited to launch a patient app which will support patients in shared decision making about their medicines. Interest in the importance of polypharmacy management is now international, and the WHO Third Global Patient Safety Challenge, Medication without Harm, has included the appropriate management of polypharmacy as a key flagship area to address. The aim is to reduce severe avoidable medication related harm by 50% over 5 years, globally.

6 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. With the publication of this Polypharmacy Guidance, Realistic Prescribing 2018, and supported by Realistic Medicine, the requirement now is that the NHS Boards will build on the foundational work of the last five years and focus resource on accelerating the capacity of polypharmacy reviews in order to further increase the benefit to patients . Alpana Mair Head of Effective Prescribing and Therapeutics Jason Leitch National Clinical Director Healthcare Quality and Improvement Dr Catherine Calderwood Chief Medical Officer 5 Acknowledgements It has been a pleasure to chair the development of third edition of Polypharmacy Guidance, Realistic Prescribing 2018, working with a team who are committed to improving outcomes for patients .

7 This has been produced by the collaborative efforts of a multidisciplinary team of clinicians, academic and policy makers from across Scotland, who are already delivering polypharmacy reviews to improve the levels of appropriate prescribing and patient safety. The development of Case Finding and clinical outcome indicators was led by Tobias Dreischulte, in collaboration with Sean MacBride-Stewart. Data relating to numbers needed to treat and adverse drug reactions have been updated by medicines information pharmacists , represented by Craig Rore. The polypharmacy app has been updated to include a new patient facing facility, developed with colleagues from Scottish Government eHealth.

8 Thanks also to those who contributed comments to the consultation. Finally, I would like to thank Jake Laurie for the support he has provided in terms of presentation of this document. Polypharmacy Model of Care Group Alpana Mair, Head of Effective Prescribing and Therapeutics, Scottish Government (Chair) Robin Balfour, GP Clinical Lead, NHS Lothian Rachel Bruce, Lead Pharmacist, NHS Greater Glasgow and Clyde Tobias Dreischulte, Lead Pharmacist Research and Development, NHS Tayside Bruce Guthrie, Professor of Primary Care Medicine, University of Dundee Findlay Hickey, Lead Pharmacist (West) North & West Operational Unit, NHS Highland Simon Hurding, Clinical Lead Effective Prescribing and Therapeutics, Scottish Government Pamela Mills, Principal Pharmacist Redesign, NHS Ayrshire and Arran Craig Rore, Lead Pharmacist, Grampian Medicines Information Centre Thomas Ross, Lead Pharmacist Inner Moray Firth Operational Unit, NHS Highland Sean MacBride-Stewart, Prescribing Adviser, NHS Greater Glasgow and Clyde Martin Wilson, Consultant Physician, NHS Highland Kate Wood, Lead Clinical Pharmacist Elderly and Rehabilitation, NHS Tayside Medicines Information pharmacists Sarah Brady, Lead Medicines Information Pharmacist.

9 NHS Lanarkshire Tracy Duff, Senior Pharmacist, NHS Lothian Tracy Love, Principal Pharmacist Medicines Information, NHS Ayrshire and Arran Sheila Noble, Senior Pharmacist Medicines Information, NHS Lothian Yvonne Semple, Lead Pharmacist Medicines Information, NHS Greater Glasgow and Clyde We are also grateful for the following for their assistance: Janette Barrie, Nurse Lead, NHS Healthcare Improvement Scotland Alison Clement, GP Clinical Lead, NHS Tayside Jason Cormack, Programme Lead Effective Prescribing and Therapeutics, Scottish Government Stuart Cummings, General Practitioner, NHS Forth Valley Colin Daly, Senior Information Analyst, NHS National Services Scotland Heather Harrison, Senior Prescribing Adviser, NHS Greater Glasgow and Clyde Colette Kerr, Lead Pharmacist Medicines Utilisation & Education, NHS Ayrshire and Arran Jake Laurie, Project Support Officer Effective Prescribing and Therapeutics, Scottish Government Dougie Lowdon, Consultant Geriatrician.

10 NHS Tayside David Maxwell, Improvement Advisor, Scottish Patient Safety Programme Simon Maxwell, Chair of Student Learning, University of Edinburgh Nils Michael, Economic Advisor, Scottish Government Michael Muirhead, Head of Service, NHS National Services Scotland Stewart Mercer, Professor in Primary Care, University of Glasgow Ruth Paterson, Programme Lead Advanced Nurse Practice and Non-Medical Prescribing, Napier Paul Paxton, Data Analyst, NHS National Services Scotland Blythe Robertson, Policy Manager (Person Centred and Self-Management), Scottish Government Ann Wales, Programme Manager (Decision Support), Scottish Government Miles Witham, Senior Clinical Lecturer in Ageing and Health, University of Dundee Alpana Mair, MRPharmS, IP, FFRPS (Chair of Polypharmacy Model of Care Group) 6 Executive Summary Caring for patients with multi-morbidities and polypharmacy is an increasing global challenge.