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Patient safety

Implementing safe and routine deprescribing in primary care

It is well documented that the use of medicines has been increasing and continues to rise as we improve how we understand, diagnose and treat different medical conditions. The UK alone has seen a 39% increase in number of medicines dispensed from 2007 to 2017 (NHS Digital, 2018). As the number of medicines available to treat patients grows, it is now commonplace for patients to take five or more medicines concurrently – also known as polypharmacy. This is especially the case for patients age 65 years and over (Gao et al., 2017).

Polypharmacy is not inherently negative and is a natural effect of our healthcare system. A patient with multiple diagnoses requires multiple medicines to treat their various conditions effectively to better quality of life. In addition, if patients experience side effects from their initial treatment plan, additional medicine may be prescribed to counteract this. This is known as the prescribing cascade. This is further intensified because clinical practice guidelines that aid prescribers in prescribing appropriate medicines are based on the idea that a patient has a single disease only (as opposed to the reality of many patients having multiple ailments). From this perspective, it’s quite easy to see how a patient may quickly end up on 5 or more long-term medicines. So, it is important to ensure the necessity of each medicine or polypharmacy risks becoming problematic.

The definition of problematic polypharmacy is instances where many medicines are prescribed inappropriately or the intended benefit of a medicine is not realised (Duerden et al., 2013). Such examples involve instances where the number of tablets a patient takes negatively affects their quality of life or when multiple medicines prescribed are hazardous because of a clinical interaction between the medicines or the cumulative effect they have on the body. This can subsequently lead to adverse drug reactions (ADRs), the use of potentially inappropriate medicines (PIMs), non-adherence to medicines and higher care costs (Pirmohamed et al., 2004). Patient safety is compromised when problematic polypharmacy is present.

An avenue for combating problematic polypharmacy is deprescribing. Deprescribing is identifying and discontinuing medicines where harms outweigh benefits in relation to each individual patient and their treatment goals (Scott et al., 2015). This is a shared decision between patients and healthcare professionals. Research has shown deprescribing to be effective in stopping PIMs whilst showing a lack of significant harm, especially when deprescribing long-term medicines (Iyer et al., 2008). However, the process of deprescribing is not completely without risk, with the risk of relapse of symptoms of the original condition or a risk of symptoms associated with stopping a medicine being present. In summary, deprescribing is important in addressing problematic polypharmacy through stopping unnecessary medicine use, but it’s not completely free of risk. It’s important that deprescribing is routinely considered but conducted safely.

Although deprescribing can help in preventing problematic polypharmacy, much of the deprescribing currently in practice is reactive, meaning a medicine is stopped once a patient has already developed side effects. To maintain patient safety, there is a need for proactive deprescribing so that problematic medicines are stopped before side effects can occur. There is a lack of evidence on how routine proactive deprescribing can occur within our current healthcare safely. Multiple obstacles to routine deprescribing have already been highlighted, including a lack of clinician’s time, competing workloads, and the fear that deprescribing may be seen as a cost-cutting exercise or abandonment of care (Reeve et al., 2013, Doherty et al., 2020). There is little guidance on how to overcome these obstacles and implement routine, safe and proactive deprescribing.

In order to combat problematic deprescribing and better patient safety, this has provided us with a drive to research how routine and safe deprescribing can be implemented into our primary healthcare. We aim to understand what patients and healthcare professionals need for routine and safe deprescribing to occur. This is very important to us as we want deprescribing to work for patients, without negatively affecting healthcare professionals. As pharmacists are known as medicine specialists, we’re also interested in the potential roles of pharmacists in supporting routine deprescribing. Research has highlighted the beneficial role of pharmacists in deprescribing, but little is known about their exact roles (Ailabouni et al., 2019).

Ultimately, we then want to co-design resources with patients and healthcare professionals that make it easier for safe and routine deprescribing to be implemented into practice. It is hoped that this will make it easier to tackle problematic polypharmacy without compromising patient safety.

Daniel Okeowo supervised by Professor David Alldred, Dr Beth Fylan and Dr Syed R. Tabish.

References:

AILABOUNI, N., MANGIN, D. & NISHTALA, P. S. 2019. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. International Journal of Clinical Pharmacy, 41, 167-178.

DOHERTY, A. J., BOLAND, P., REED, J., CLEGG, A. J., STEPHANI, A. M., WILLIAMS, N. H., SHAW, B., HEDGECOE, L., HILL, R. & WALKER, L. 2020. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open, 4.

DUERDEN, M., AVERY, T. & PAYNE, R. 2013. Polypharmacy and medicines optimisation: Making it safe and sound [Online]. The King’s Fund, 11–13 Cavendish Square, London W1G 0AN: The King’s Fund.  [Accessed].

GAO, L., MAIDMENT, I., MATTHEWS, F. E., ROBINSON, L., BRAYNE, C., FUNCTION, O. B. O. T. M. R. C. C. & STUDY, A. 2017. Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II. Age and Ageing, 47, 220-225.

IYER, S., NAGANATHAN, V., MCLACHLAN, A. J. & LE COUTEUR, D. G. 2008. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging, 25, 1021-31.

NHS DIGITAL. 2018. Prescriptions Dispensed in the Community – Statistics for England, 2007-2017 [Online]. Available: https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-england—2007—2017 [Accessed].

PIRMOHAMED, M., JAMES, S., MEAKIN, S., GREEN, C., SCOTT, A. K., WALLEY, T. J., FARRAR, K., PARK, B. K. & BRECKENRIDGE, A. M. 2004. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ, 329, 15-19.

REEVE, E., TO, J., HENDRIX, I., SHAKIB, S., ROBERTS, M. S. & WIESE, M. D. 2013. Patient Barriers to and Enablers of Deprescribing: a Systematic Review. Drugs & Aging, 30, 793-807.

SCOTT, I. A., HILMER, S. N., REEVE, E., POTTER, K., LE COUTEUR, D., RIGBY, D., GNJIDIC, D., DEL MAR, C. B., ROUGHEAD, E. E., PAGE, A., JANSEN, J. & MARTIN, J. H. 2015. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine, 175, 827-834.