In the past 15 years there has been a 4% increase in the number of patients taking 10 or more medicines. On 20 April 2015, I attended a joint conference between the Royal College of General Practitioners (RCGP) and the Royal Pharmaceutical Society (RPS), which discussed the issues around the “necessary evil” of polypharmacy and how best to tackle it.
For patients with multiple morbidities, healthcare professionals need to look at the whole picture rather than treating individual conditions in silo. “We should be trying to work out how we deal with commonly associated co-morbidities and find one-stop solutions rather than dragging patients from one clinic to another,” said GP Martin Duerden.
Ruthe Isden from charity Age UK said that the conversation between health professionals and their patients should focus on what quality of life is for the patient. “Is it absence of pain? Being able to do the things you want to do?” she asked. “Often there are non-medical alternatives which can support people in different ways and help them better achieve their goals.”
Deprescribing is as important, and legal, as prescribing
As a prescriber, asking whether or not a drug is still needed is just as important as prescribing a new drug.
“There may be other ways to manage a patients’ condition”, said Duerden, “Exercise, arts, education, social contact — these can all result in a dramatic improvement without the need for medicines.”
Much of what holds health professionals back from deprescribing is a fear of litigation. But as Rupert Payne, GP and consultant senior lecturer at the University of Bristol, pointed out: “There is no legal difference [between prescribing and deprescribing] only a lack of an evidence base.”
However, convincing patients that they no longer need their medicines is another significant challenge that needs trial and review. “It requires time, more manpower, personalised care, named doctors and training,” said Duerden.
Put patients at the centre of their care
Care should always centre on the patient’s primary needs. “The gap [in polypharmacy] is in the patient perspective” said consultant pharmacist Nina Barnett, “ask patients what’s important to them – let them be in control.”
Jeremy Taylor, chief executive of National Voices, laid out four rules he thought were key to patient-centred care: “See the person (not the illness); care for me; join up your services around me; don’t take over.”
During a Q&A session, Barnett and Duerden discussed labelling prescriptions clearly with what the medicine is for. “Patients often don’t know why they’re taking a medicine.” said Duerden. However, Barnett emphasised that labelling needs to be with the patients’ consent, “if someone has a prescription for Viagra – they may not want everyone in the pharmacy knowing!”
Patient decision aids are a tool that can make it easier for clinicians to have conversations with their patients about risk enabling patients to make informed decisions about their medicines.
Those recommended by Julian Treadwell, a GP and vice-chair of the Overdiagnosis Group at the RCGP, included the National Institute for Health and Care Excellence (NICE) statin decision aid, anti-coagulation decision aid, type 2 diabetes glycaemic targets decision aid and hormone replacement therapy risk estimates. “We need better resources, better public education and better doctor education, medicines don’t work for everyone – it should be a choice,” he said.
Be aware of your language
“Why do we use such dreadful jargon?” asked Taylor, “why not English?”
“What does ‘deprescribing’ mean to a patient?” said Barnett, “it’s open to misinterpretation and can come across as being cost motivated. We need to use different language.”
Treadwell added that doctors should also take care with language when prescribing. “Don’t say ’this will stop you having a heart attack’, because they will refuse to stop it.”
Remember Dr Google
“Remember that patients Google!” pointed out a delegate. Patients have more time to research their medicines than their doctor so could end up knowing more.
“Dr Google works much longer hours than any doctor!” Duerden concurred. If possible, sit down with the patient and guide them to the right sources of information and away from those that contain misleading information. Negotiation is a key clinical skill.
GPs and pharmacists should work together
“GPs simply don’t have time to deal with the problems associated with polypharmacy” said Duerden.
“Prescribing targets are a huge source of pressure for GPs. They can spend 60 hours on repeat prescriptions” said another GP Mike Holmes: “Pharmacists in GP practices can relieve this pressure.”
Another delegate at the conference described the ‘Walk in my shoes’ initiative, in Lewisham, South East London, where GPs and pharmacists spend a day in each other’s roles to learn more about what each other does.
Taylor highlighted that if prescribing is not well co-ordinated between healthcare professionals it can result in reduced safety and an increased burden on the patient. “The patient ends up being on a treadmill and 100% adherence is often not possible.”
A recurring theme throughout the conference was that of courage. Courage is key when dealing with polypharmacy as little research data is available to support decision making, especially when it comes to deprescribing.
Treadwell highlighted that practitioners “need courage to deviate from NICE guidelines” if it is in the best interest of the patient.
Pharmacists and GPs need to be brave in order to change the way they work with polypharmacy.