Appropriate prescribing toolkit: Further reading, articles and resources of interest
This page forms part of the Appropriate prescribing toolkit. Use the links in the left hand menu to return to the main toolkit page or access the additional sections.
1. WHO technical report – medication safety in polypharmacy
World Health Organization. 2019. Medication Safety in Polypharmacy. Geneva: World Health Organization. (WHO/UHC/SDS/2019.11). Licence: CC BY-NC-SA 3.0 IGO. Download a copy (2.7 MB, pdf)
As the population ages more people are likely to suffer from multiple long-term illness and take multiple medicines. It is therefore essential to take a person-centred approach to ensure the medicines are appropriate for the individual to gain the most benefits without any harm. This report highlights the importance of leadership in nurturing a culture that priorities safety and quality of prescribing, provides guidance on prioritising patients for medication review, the role of the patient and the importance of a multi-professional team across the health and care system, including policy makers. Included are tools and case studies that illustrate a systematic approach that can be followed by all health care professionals and the patient, across the health and care system, so patients are integral to making decisions about their medicines and feel supported to do so.
2. Frailty care guides – deprescribing and polypharmacy
Health Quality & Safety Commission. 2019. Frailty care guides – deprescribing and polypharmacy. Wellington: Health Quality & Safety Commission.
Aimed at registered nurses in aged residential care, this provides guidance on deprescribing statins, proton pump inhibitors (PPIs), sedatives and hypnotics (eg, temazepam, zopiclone), antipsychotics (eg, haloperidol, risperidone) antihypertensives and anticholinergic medicines.
3. Polypharmacy Guidance: Realistic Prescribing, 3rd edition 2018
Scottish Government Polypharmacy Model of Care Group. 2018. Polypharmacy Guidance: Realistic Prescribing (3rd Edition). Edinburgh: NHS Scotland. Download a copy (2.8 MB, pdf)
The Scottish Polypharmacy Guidance aim is to help health care professionals to work in partnership with patients to make shared decisions that will ensure their medicines are safe and appropriate and support what matters most to them in their lives.
This resource outlines a seven-step process, which provides a clear structure for both the initiation of new treatments, and the review of existing treatments.
- Step 1: What matters to the patient
- Step 2: Identify essential drug therapy
- Step 3: Does the patient take unnecessary drug therapy?
- Step 4: Are therapeutic objectives being achieved?
- Step 5: Is the patient at risk of ADRs or suffers actual ADRs?
- Step 6: Is drug therapy cost-effective?
- Step 7: Is the patient willing and able to take drug therapy as intended?
Throughout, there is a central emphasis on ‘what matters to the patient?’ as a key driving force for decisions. The resource also provides patients and health care professionals with summary information about numbers needed to treat (NNT) for various medicines. The NNT is the average number of patients who need to be treated to prevent one additional bad outcome. This information may provide a starting point for the conversation between the health professional and patient about the likelihood of benefit from different medicines and, in some cases, the potential for other approaches such as self-management.
Available in three formats:
- PDF www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
- Website www.polypharmacy.scot.nhs.uk/polypharmacy-guidance-medicines-review/
- App https://play.google.com/store/apps/details?id=com.tactuum.quris.nes.polypharmacy&hl=en
4. Reducing inappropriate medication use by implementing deprescribing guidelines
McCarthy D. 2017. Reducing inappropriate medication use by implementing deprescribing guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement. URL: https://bit.ly/2AZ4X8i | Download a copy (532 KB, pdf)
A multidisciplinary team of clinical experts in Ottawa, Canada, created a credible, low-cost process for developing and implementing evidence-based deprescribing guidelines and tools for assessing, tapering, and stopping medicines that may cause harm or no longer benefit patients.
Although the guidelines led primary care teams to consider approaches for identifying such medications and engaging patients in conversations about discontinuing them, the intervention has thus far been more successful in long-term care settings, where it strengthened team-based medication reviews in fulfilment of routine quality improvement and reporting requirements.
5. Implementation guide: Reducing inappropriate medication use by implementing deprescribing guidelines
Pelton L, Knihtila M. 2018. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines — Implementation Guide. Boston, Massachusetts: Institute for Healthcare Improvement. URL: https://bit.ly/2XRLtfa | Download a copy (857 KB, pdf)
The implementation guide provides details on implementing the deprescribing innovation based (reference above) on the experience of US health care systems participating in the International Innovations Network Learning and Action Community, led by The Commonwealth Fund and IHI.
6. Polypharmacy and medicines optimisation. Making it safe and sound
This appraises the literature on polypharmacy and medicines optimisation.
7. Current policies and guidelines
Stewart D, Mair A, Wilson M, et al and SIMPATHY consortium. 2016. Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments. Expert Opinion on Drug Safety 16(2): 203–13. URL: http://doi.org/10.1080/14740338.2017.1265503 | Download a copy (845 KB, pdf)
A systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter’s eight step process for leading sustainable change.
8. Polypharmacy initiatives
McIntosh J, Alonso A, MacLure K, et al, on behalf of the SIMPATHY Consortium. 2018. A case study of polypharmacy management in nine European countries: Implications for change management and implementation. PLoS ONE 13(4): e0195232. URL: http://doi.org/10.1371/journal.pone.0195232 | Download a copy (1.7 MB, pdf)
This provides examples of polypharmacy management initiatives that can help managers and policy makers develop new programmes or scale-up existing ones, particularly in places currently lacking such initiatives.
9. PHARMAC resources
Managing polypharmacy and deprescribing
- Introduction – overview of polypharmacy and MIAP – Dr Ian Hosford
- Managing polypharmacy – GP/palliative care perspective – Dr Marion Taylor
- Managing polypharmacy – pharmacist perspective – Fiona Corbin
- Managing polypharmacy – case-based discussion – Dr Jan Gregson
Managing the risks of polypharmacy in chronic disease
- Polypharmacy – setting the scene – Dr Tim Maling
- Five key issues in the management of polypharmacy – Fiona Corbin
- Human factors influencing safe medicines use – patient and prescriber – Dr Brian Robinson
- Pharmacodynamic principles for safe practice (getting the dose right, common drug and disease interactions) – Dr Tim Maling
- Prescribing appropriately (worked examples) – Dr Tim Maling
10. Learning module
- Polypharmacy bohemian rhapsody (YouTube)