Managing and reducing polypharmacy when prescribing

Introduction

Polypharmacy is the concurrent use of multiple medications. It lacks a universally agreed clinical definition, but is commonly referred to as the regular use of five or more drugs^​1​. This encompasses the full range of substances, including over-the-counter, prescription, illicit and traditional or complementary medicines used by patients.

Polypharmacy is a significant global health concern observed across various healthcare settings worldwide. Differences in healthcare structures and data collection methods, along with varying definitions of polypharmacy, make cross-country comparisons challenging but the prevalence of polypharmacy is expected to rise in the UK and globally during the coming decades^​1​. This owes to several factors including demographic shifts, such as an ageing population, growth in multimorbidity and long-term conditions and the continued development of new drugs and the associated expansion of treatment options^​1,2​. 

The routine practice of polypharmacy carries risk, as the potential benefits of several medications may be outweighed by the adverse effects resulting from the volume of drugs administered. Assessment of polypharmacy extends beyond quantity, prompting consideration of each medication’s effectiveness, suitability and potential harm, whether used individually or in combination^​3​.

When evaluating polypharmacy, the aim should be to reduce inappropriate polypharmacy and ensure appropriate use of medicines that are optimised in alignment with the individual needs and preferences of the patient (see Box). Therefore, appropriate polypharmacy should be considered whenever a new treatment is initiated for a patient and especially when the patient transitions between different healthcare settings or is diagnosed with multiple comorbidities^​1​.

This article explores some of the challenges that management of multiple medicines presents for prescribers and introduces approaches that prescribing pharmacists can take to support patients.

It is recommended that you read this article in conjunction with these resources from The Pharmaceutical Journal:

• ‘How to conduct a clinical review of a patient’s medicines’;
• ‘How to build and maintain trust with patients‘;
• ‘Principles of person-centred practice for prescribing’;
• ‘How to provide patients with safety-netting advice’;
• ‘PJ Pod: Effective deprescribing: getting the most from medicine’.

Issues and challenges of polypharmacy

Managing multiple medications presents a range of challenges. Patients with a large number of prescribed medicines will interact frequently with the healthcare service and as a consequence are exposed to increased risk of medication-related harm. The complexity that comes with polypharmacy can also lead to resource intensive interventions and increased economic burden placed on the health system^​1​. Polypharmacy can also result in a ‘prescribing cascade’ where a new medicine is prescribed in response to an adverse reaction to another drug rather than as a response to a genuine medical condition.

Polypharmacy also makes clinical decision making more challenging and introduces greater levels of treatment uncertainty. Despite advances in pharmacotherapy, evidence-based clinical guidelines for older adults with multiple morbidities are limited and will often require the application of clinical judgement and shared decision making to establish the best course of action for each individual patient. Much of the clinical trial data that informs the evidence-base derives from studies focussed on single-disease and it is not possible for clinical guidance to account for all possible combinations of illnesses, treatment combinations and patient factors. In these circumstances, prescribing pharmacists need to be confident in applying their expert knowledge of medicines and pathophysiology and work collaboratively with the patient to identify the best approach to take.

The objectives of polypharmacy management should focus on improving health outcomes, achieving an optimised balance between disease control, side effects and interactions, increasing patient engagement in treatment decisions, while considering cost-effectiveness and allocation of resources within the healthcare system. Polypharmacy management is in alignment with health system improvement strategies, such as the ‘triple aim; strategy, which targets improved care, health, and cost effectiveness; and NHS national guidance (e.g ‘National medicines optimisation opportunities 2023/2024‘ and the ‘National overprescribing review report‘)^​4​.

Importance of patient preference, shared decision making and empowerment 

When considering polypharmacy, it is essential to involve patients in the decision-making process and empower them with knowledge about their medications and potential side effects to they can take an active role in managing their health. Shared decision-making acknowledges patient preferences, values, and treatment goals, fostering a collaborative relationship between prescribers and patients^​5​.

Prescribers must navigate the delicate balance between the risks and benefits of pharmacotherapy and be able to communicate this to patients. When discussing treatment regimens with patients, it is essential to:

• Using open communication explain the rationale behind each medication, including its intended benefits and potential risks. This involves providing patients with clear, understandable information about why each medication is being prescribed, how it works to manage their condition, and the outcomes they can expect. It is important to discuss potential side effects or adverse reactions to ensure patients are fully informed about the risks associated with each medication;
• Discuss alternative treatment options and their respective risks and benefits. In addition to discussing the prescribed medication, healthcare providers should also explore alternative treatment options with patients. This may include non-pharmacological approaches, different medication formulations, or alternative therapies^​5,6​;
• Emphasise the importance of medication adherence and regular follow-up to monitor treatment effectiveness, complications and safety. It is crucial to stress the importance of adhering to the prescribed medication regimen as directed to achieve optimal treatment outcomes keeping open to the possibility of making future changes and adjustments. 

Identifying patient factors that contribute to polypharmacy risk

There are multiple opportunities for prescribers to identify polypharmacy risk throughout the prescribing process and it is important to be aware of specific groups and relevant patient factors that may indicate higher polypharmacy related risk.

Examples include individuals:

• With multiple chronic conditions requiring several medications;
• Who receive prescriptions from multiple healthcare providers;
• Who are older adults, as they are more susceptible to medication-related problems;
• With a history of adverse drug reactions or drug interactions.
• With low levels of health literacy or in lower socio-economic groups and more likely to have long-term health conditions than people in higher socio-economic groups^​1,7​.

Comorbidities

Each additional condition adds complexity to the treatment regimen, increasing the likelihood of polypharmacy. For instance, a patient with diabetes, hypertension and arthritis may require multiple medications to manage each condition effectively. Healthcare providers must carefully consider potential drug interactions, contraindications, and duplications when managing multiple comorbidities to minimise polypharmacy-related risks.

Age 

Older adults often have multiple chronic conditions and physiological changes associated with aging influence drug metabolism and response. Age-related changes in renal function, liver metabolism, and body composition can alter the pharmacokinetics and pharmacodynamics of medications increasing susceptibility to adverse drug reactions and drug interactions^​8​. Furthermore, older adults may experience age-related cognitive decline, sensory impairments, or mobility issues that impact their ability to manage medications independently, further contributing to polypharmacy risk.

Healthcare providers should assess cognitive function when prescribing medications and consider simplified treatment regimens or caregiver support to mitigate polypharmacy-related risks in this population.

Socio-economic status 

Access to healthcare services and affordability of medications can impact medication adherence and polypharmacy risk. Patients with limited access to healthcare resources, such as those in lower socio-economic groups and marginalised communities, may face barriers to obtaining timely medical care, diagnostic tests, prescription medications and appropriate monitoring and review.  Prescribers should be alert to these factors and work towards reducing these barriers and making use of medication affordability programs, and initiatives that improve access to primary care services.

Strategies to manage and reduce polypharmacy risk

Pharmacists play a crucial role in the management of polypharmacy by leveraging their accessibility to patients and expertise in pharmacology and medication use.  They can also take a lead on educating and advising the wider multidisciplinary team about adverse reactions and polypharmacy risk.

One of the most powerful tools for managing polypharmacy effectively is clinical pharmacist-led medication reviews which have shown promising results contributing to reduced hospital and emergency department visits, reduced medication-related readmissions, significant cost savings and improved patient outcomes^​6​. Scaling up such interventions could further reduce morbidity and enhance healthcare cost reductions^​9​.

Comprehensive medication reviews can identify inappropriate prescribing, drug interactions, duplications and opportunities to deprescribe drugs that are no longer needed or may no longer be beneficial to the patient. When an opportunity to actively manage polypharmacy is identified, prescribers should adopt a structured and person-centred approach (see Figure). The medication review also provides an opportunity to identify patient preferences, agree goals, identify problematic medicines and agree actions. They also provide a means of evaluating effectiveness of changes, monitoring and making further adjustments.

Reproduced from European Journal of Pharmacy/The Pharmaceutical Journal

Possible actions 

There are a multitude of possible actions that can be agreed when managing polypharmacy depending on the unique circumstances and preferences of the patient, a selection of which are summarised below along with a supporting case example.

Simplify regimens

Medication regimens should be consolidated whenever possible to minimise pill burden and improve adherence. This could involve switching to combination therapies, extended-release formulations, dosage adjustments that streamline the treatment regimen or align medicine timings with the patient’s daily routine.

In all decisions, consideration needs to be given (where possible) to the patient’s ability to manage their medications independently.

Integration of non-pharmacological therapies

Non-pharmacological interventions, such as lifestyle modifications, physical therapy and complementary therapies, can complement pharmacotherapy and potentially reduce reliance on medications. Lifestyle improvement has also been shown to attenuate polypharmacy effects^​10​. Incorporating lifestyle interventions into the treatment plan can address underlying health issues, improve overall well-being and potentially reduce the need for multiple medications. This may involve referrals to specialists, social prescribing or utilising resources available within the local community (e.g. charities, voluntary organisations, faith groups).

Non-pharmaceutical therapies should be integrated into the patient’s overall treatment plan so they are able to complement their current pharmacotherapy. Review of these interventions should be included in the regular review and monitoring to make any necessary adjustments.

Deprescribing

In some circumstances, prescribers may be able to identify opportunities to systematically discontinue or reduce medications that are agreed to be unnecessary, ineffective, or pose risks to patient safety. This process involves careful consideration of the potential benefits and harms of each medication, prioritising patient safety and wellbeing. 

Consideration of the patient’s disease progression, priorities, quality of life and treatment goals should be central to the assessment and decision making process. Prescribers should prioritise medications that have the highest risk of adverse effects or the least therapeutic benefit. Deprescribing should be approached cautiously and adopt ain gradual approach with suitable monitoring for withdrawal symptoms or a resurgence of the underlying condition.

Initiating or modifying treatment regimens — prescribing within your scope of competence

When managing polypharmacy prescribers must adhere to their clinical area of expertise and ensure that their prescribing decisions are evidence-based, patient-centred, and aligned with best clinical practices. Consideration should be given to your scope of practice with suitable consultation and referrals made. Patients with multimorbidity are likely to receive treatment and support from across the multidisciplinary team drawing from a range of specialisms and healthcare setting. It is important to consider the full context and adopt a patient-centred approach.

Before initiating or modifying treatment regimens, prescribers should:

• Understand the condition(s) being treated, including their natural progression, severity and anticipated response to treatment. This involves a comprehensive understanding of the pathophysiology, diagnostic criteria and evidence-based treatment guidelines for each patient’s condition. Prescribers should consider factors such as disease stage, comorbidities, and potential complications to tailor treatment plans to individual patient needs effectively;
• Continuously reassess and adjust treatment plans based on patient response and evolving clinical circumstances. The patient’s progress should be regularly monitored, treatment effectiveness assessed and evaluate adverse effects or complications. This ongoing reassessment allows prescribers to make timely adjustments to treatment plans, such as dose modifications, medication substitutions, or discontinuations, to optimise therapeutic outcomes while minimising risks. Additionally, prescribers should remain vigilant for changes in patient clinical status, including new comorbidities, medication interactions or changes in functional status, that may necessitate modifications to the treatment approach.

There are many examples of tools to support reviewing medicines and safely tapering or withdrawing ones that are no longer appropriate: 

• PrescQIPP’s Polypharmacy and deprescribing webkit^​11,12​; 
• ‘NO TEARS’ tool^​13​;
• ‘STOPP-START, Beers criteria 2019^​14,15​;
• Scotland Polypharmacy Guidance 2018^​16​; 
• Australian ten-step discontinuation guide^​17​; 
• NHS Specialist Pharmacy Service patient-centred approach to polypharmacy and the Canadian MedStopper tool^​18,19​.

Further information and links to these resources can be found at the end of the article.

The following case scenario explores many of the principles introduced by this article in a practice context. 

Case in practice

Jane Doe, a 72-year-old woman, attends a routine medication review clinic with the prescribing pharmacist for a routine check-up. She has a history of hypertension, type 2 diabetes mellitus, osteoarthritis and anxiety. Mrs Doe is currently taking eight different medications, including some over-the-counter supplements. She reports feeling overwhelmed by her medication regimen and experiencing side effects like dizziness and fatigue.

During the consultation, the pharmacist notices that Jane is prescribed multiple medications that may not be necessary and could be contributing to her symptoms. The pharmacist takes the following steps to identify and manage Mrs Doe’s polypharmacy:

Step 1: Conduct a comprehensive medication review

The pharmacist reviews all of Mrs Doe’s current medications, including prescription drugs, over-the-counter medications and supplements. He identifies potential drug interactions and redundancies in her treatment plan.

Step 2: Conduct a patient-centred conversation to explores options, preferences and goals

The pharmacist engages Mrs Doe in a discussion about her health goals and concerns. He listens empathetically as she describes her difficulties managing the medication regimen and the side effects she is experiencing.

Step 3: Identify actions 

The pharmacist identifies that Jane is taking two medications for anxiety from different providers, leading to unnecessary duplication. He discusses with Mrs Doe the possibility of tapering off one of the anxiety medications under supervision.

He also notices that Mrs Doe is taking a high-dose NSAID for osteoarthritis pain, which may be contributing to her dizziness and fatigue. The pharmacist suggests an alternative pain management strategy, including a lower dose of NSAID combined with physical therapy exercises.

Step 4: Coordinate with other healthcare providers to discuss and implement changes

The pharmacist contacts Mrs Doe’s psychiatrist to discuss the proposed changes to her anxiety medication. Together, they agree on a plan to streamline her medications and monitor her closely for any adverse effects.

Step 5: Provide suitable patient education 

With the changes agreed, the pharmacist educates Mrs Doe about the importance of medication adherence and the potential side effects of her medications. He places emphasis on empowering Mrs Doe to better understand her use of medicines. He provides her with a simplified medication schedule and written instructions to help her manage her medications more effectively and carefully checks that she has fully understood the changes

Step 6: Provide follow-up and monitoring

The pharmacist schedules a follow-up appointment with Mrs Doe to monitor her progress and make any necessary adjustments to her treatment plan. He also sets up regular phone check-ins to address any concerns she may have between visits.

Over the next few months, Mrs Doe’s medication regimen is successfully simplified, leading to a reduction in side effects and improved quality of life. She reports feeling more in control of her health and less overwhelmed by her medications. Mrs Doe appreciates the collaborative approach taken by the pharmacist and her other healthcare providers, which has resulted in more person-centred and effective management of her chronic conditions.

Knowledge check