Reducing Inappropriate Polypharmacy

Standard versions:

Health Innovation Network resources to support Structured Medication Reviews (available in a range of languages) 

• Invitation for an SMR 03086-A4-Patient-Invitation-Letter_ENG.pdf (thehealthinnovationnetwork.co.uk)  

• ‘Safely stopping your medicines’ 03086-A4-Stopping-your-Medicine-Guide_ENG.pdf (thehealthinnovationnetwork.co.uk) 

• Editable structured medication review: summary and next steps form Structured Medication Review Summary Form

• Me and my medicines charter – encourages clinicians to support people to ask about their medicines, to agree together a shared approach to overcome any issues around their medicines 03086-A4-Me-and-My-Meds-Charter_ENG.pdf

• ‘Are your medicines working for you?’ symptom tracker Symptom tracker_ENG (thehealthinnovationnetwork.co.uk) 

Easy read versions:

·       Patient invitation letter – easy read 4260 NHS Health Innovation West of England - Patient Invitation Letter - Easy Read v4 copy

·       Safely stopping your medicine leaflet – easy read 4260 NHS Health Innovation West of England - Stopping your medicine Guide - Easy Read v2_ENG

·       Me and My Medicines Charter – easy read Me and My Medicines Charter - easy read

268. IMPACT 2021 2.0 (updated July 2024 v4.1)  

This bulletin provides suggestions for consideration by commissioning organisations and clinicians to optimise medicines use and provide practical advice (where it is available) about how to safely stop/ discontinue/withdraw a medicine and issues to consider. 

Polypharmacy and deprescribing  

Includes resources in this key area and links to examples of good practice in medicines optimisation, medication review and appropriate polypharmacy nationally and internationally. 

Additional resources include algorithms to support the deprescribing of specific medicines, flow chart, case study and patient letter. 

MedStopper is a tool to help clinicians and patients make decisions about reducing or stopping medications. By entering the list of medications a patient is receiving, Medstopper sequences the drugs from "more likely to stop" to "less likely to stop", based on three key criteria: the potential of the drug to improve symptoms, its potential to reduce the risk of future illness and its likelihood of causing harm. Suggestions for how to taper the medication are also provided. 

A useful tool for structuring a polypharmacy review / SMR  

Using the NO TEARS tool for medication review | The BMJ  

Anticholinergic burden (ACB) is the cumulative effect on an individual of taking one or more medicines with anticholinergic activity. An increasing number of systematic reviews and meta-analyses report that medicines with anticholinergic effects are associated with an increased risk of cognitive impairment, falls and all-cause mortality in older people. 

A number of the most widely used anticholinergic burden tools are listed below: 

Anticholinergic Cognitive Burden Scale (Aging Brain Program of the Indiana University Center for Aging Research) Anticholinergic-Burden-Scale.pdf
ACB Calculator ACB Calculator 
Medichec Medichec 
 
NHSBSA Medication Safety – Indicators list of drugs with moderate to high anticholinergic activity  Medication Safety -Indicators Specification (nhsbsa.nhs.uk) 

HWE ICB Hints and tips for anticholinergic burden (ACB) medication reviews 

HWE ICB Guidance on Anticholinergic Burden Structured Medication Reviews using Eclipse Live 

Herts and West Essex ICB Q&A document to support the review of repeat prescribing and reducing harm from overprescribing 

Introduction to Overprescribing and IMPACT Tool - ECF 2024/25

For the ECF 24/25, each practice or PCN must nominate a ‘Reducing Harm from Medicines’ Champion who is required to attend 2 hours of training pPovided by PMOT on deprescribing/overprescribing/IMPACT tool.

This training is a requirement of the ECF for 24/25 but attendance is not limited to the ‘Reducing Harm from Medicines’ champion, any clinician involved in reducing inappropriate polypharmacy is welcome to join and these sessions will support clinicians in identifying and stopping problematic polypharmacy.

Reducing Harm from Medicines Training and Drop In Sessions

This document provides 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’. Drug Efficacy (NNT) tables provide the relative clinical efficacy of common interventions, for the patient. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/09/Polypharmacy-Guidance-2018.pdf 

The following guide has been created in order to help support medicines optimisation in older patients who may be subject to inappropriate polypharmacy, and includes practical guides for stopping the following groups of medications:

-          Antihypertensives

-          Benzodiazepines and Z-drugs

-          Oral corticosteroids

-          Antidepressants

-          Bisphosphonates

-          Acid suppressants

-          Opioids in non-cancer pain

-          Gabapentinoids in neuropathic pain

-          Antipsychotics to treat non-cognitive symptoms of dementia

-          Acetylcholine esterase inhibitors and memantine in dementia

The guide helpfully gives a 4-step practical approach to be considered when stopping medication:

1. Recognise the need to stop.

2. Reduce or stop one medicine at a time.

3. Consider if the medicine can be stopped abruptly or should be tapered.

4. Assess risk benefit after each medicine has been stopped.

All Wales Therapeutics and Toxicology Centre Polypharmacy in older people: A guide for healthcare professionals

PrescQIPP Documenting outcomes from medication review 

This bulletin provides support for evaluating the cost benefit of medication reviews, with a focus on potentially avoidable hospital admissions 

Polypharmacy - The Health Innovation Network

The Health Innovation Network National Polypharmacy Programme shares best practice on polypharmacy, accelerates learning and delivers national spread of innovation at pace and scale, through a series of national webinars, education and training, and publications to support practitioners in tackling problematic polypharmacy and overprescribing.

The mechanics of tackling overprescribing and problematic polypharmacy

A manual to help Integrated Care Boards (ICBs), Primary Care Networks (PCNs) and GP practices think about how to organise teams to tackle overprescribing and problematic polypharmacy

The manual includes:

1)      Why we should we care about overprescribing and problematic polypharmacy – including real patient stories

2)      The nuts and bolts of overprescribing stewardship and how to best deal with them – including evidence-based medicine, shared decision making, repeat prescribing, medicines reconciliation and structured medication reviews

3)      Why overprescribing and problematic polypharmacy are everybody’s responsibility

4)      Measuring progress.

An evidence-based polypharmacy Action Learning Set (ALS) for GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely.

INTEREST LIST Polypharmacy Action Learning Set - Home

A series of webinars that support clinicians to understand areas of focus relating to safe prescribing and reducing problematic polypharmacy.

Webinar series: Medication safety | RCP Medical Care

·       Safety during transitions of care

·       Problematic polypharmacy

·       Deprescribing: Safely reducing problematic polypharmacy

This toolkit aims to support clinicians caring for patients with multiple medications who are admitted to acute care. It outlines key presentations and complications of polypharmacy. It provides service recommendations for acute hospitals and guidance on quality improvement measures and sustainability.

Acute care toolkit 17: Managing multiple medications

Deprescribing.org 

Contains deprescribing guidelines and algorithms, and patient information pamphlets 

 RPS Medicines and falls   

This document is intended to provide information and guidance on medication review for people at risk of falls. It identifies a list of medicines that can cause or contribute to falls (“falls risk increasing drugs” (FRIDs)), and other medicines that cause or contribute to fractures. Therefore, effective medication review is essential for people who are at risk of falls or fractures. The document suggests a process and areas that anyone reviewing medicines for people at risk of falls might want to think about as part of their review.  

Painkillers Don't Exist 

Painkillers Don’t Exist is an NHS campaign that aims to raise awareness of the dangerous effects of pain medication and empower people living with pain to make informed decisions about their health.  

Stopping The Over‑Medication of children and young People with a learning disability, autism or both (STOMP) and Supporting Treatment and Appropriate Medication in Paediatrics (STAMP) 

Public Health England have estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both are taking a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder). A substantial proportion of people with a learning disability, autism or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn.  

This document aims to provide support to begin the process of challenging continued use of inappropriate antipsychotics in people with a learning disability, autism or both. 

Managing cardiovascular disease in frail older people – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice 

A useful document that takes practitioners through the principles for managing CVD in older people, and applying medicines optimisation principles, where CVD should not be managed in isolation in older people, but in the context of frailty, multimorbidity and other vulnerabilities.