How often would you say that prescribers routinely consider stopping prescribed medicines, particularly for elderly patients? How often do pharmacists think about prompting prescribers to do this? An ageing population means that potentially inappropriate medication may affect more patients. Polypharmacy increases the risk of side effects and drug interactions, and non-adherence leads to falls, hypoglycaemia and unnecessary hospital attendances, for example.
Pharmacists should be braver in prompting doctors to review the need for medicines periodically. We have formed this opinion based on work producing a ‘STOPIT’ tool, developed with the Collaboration for Leadership in Applied Health Research & Care (CLAHRC) for north-west London, which aids medicines reviews, with a particular focus on older patients
. Changes made to medicines can be simple, for example, withholding, reviewing and then stopping long-standing quinine sulphate treatment for night cramps, and stepping down proton pump inhibitor treatment in the absence of a clear indication. A specific example is a patient who is over 100 years old and was admitted to our elderly care rehabilitation unit on 12 long-standing medicines. By stopping five of these during an early consultation, in accordance with her physiological status and her preferences, her pill-burden was reduced by eight tablets a day, equating to 3,000 tablets a year.
This intervention also has the potential to reduce the incidence of side effects, reduce medicines waste and improve patients’ experiences with medicines. Reviewing and stopping medicines will contribute to the national agenda on improving patient safety. In the example patient, savings were estimated to be around £250 per year in medicines costs alone, which highlights the opportunities available for pharmacists to help optimise medicines and bring additional financial benefits.
The STOPIT initiative quickly prompted a change in our mindset, not just critically reviewing a medicines regimen during consultations and ward rounds, but also evaluating which medicines may be inappropriate. We would like to see doctors and pharmacists everywhere adopting this mindset.
Often pharmacists might be hesitant to encourage doctors to review medicines because they may fear something going wrong, be concerned about upsetting the patient, not want to question what another clinician has prescribed, or not have enough time to follow up changes. We recognise that a good relationship and communication between doctors and pharmacists is important in order to maximise the benefits of reviewing and stopping medicines, but pharmacists could also be a bit bolder.
Pharmacists should be encouraged to reflect on their own approach to reviewing medicines and recommending those that might be stopped. It is not always complicated and the benefits are potentially far-reaching.
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for north-west London. The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.