Which patients should be targeted for review?

Patients at highest risk of inappropriate polypharmacy are those with the greatest frailty, on the most medicines and taking high risk medicines. There has been a comprehensive review of the case finding criteria by which patients, who may benefit the most from a polypharmacy review are identified. In the previous version of this guideline, these criteria were based on age, residency in a care home, number of repeat medicines prescribed and Scottish Patients at Risk of Readmission and Admission (SPARRA) score of 40-60% (Appendix G).

Emerging trial evidence demonstrates the importance and impact of targeting patients with high-risk prescribing.^5-13Holistic face-to-face review of these patients reduced risk for the individuals and also demonstrated a reduction in hospital admissions for acute kidney injury. The success of this approach has been used by the guideline development group to consider a wider range of Case Finding indicators to target patients on high risk medications (Appendix E).

Another important area that the guideline development group considered was the effect of deprivation on rates of polypharmacy. The review of polypharmacy prescribing data (10+ BNF paragraphs plus a high risk medicine) by deprivation demonstrates that multi-morbidity, and its associated problems, presents 10 to 15 years earlier in more deprived communities.

The following revised case finding criteria are recommended as a way to prioritise patients for a polypharmacy medication review:

Aged 50 years and older and resident in a care home, regardless of the number of medicines prescribed
Approaching the end of their lives: adults of any age, approaching the end of their life due to any cause, are likely to have different medication needs, and risk versus benefit discussions will often differ from healthy adults with longer expected life spans. Consider frailty score (see section 1.6.1)
Prescribed 10 or more medicines (this will identify those from deprived communities where the average age is lower when taking 10 or more medications)
On high-risk medication (as defined by the Case Finding indicators (Appendix E), regardless of the number of medicines taken

High Risk Medicines

During a study in 2004 carried out by Pirmohamed⁶⁴ into the burden of Adverse Drug Reactions (ADRs) on hospital admissions, a number of high risk medicines were identified; they are:

BNF Section	Examples
2.1 Positive inotropic medicines	Diclofenac, digoxin
2.2 Diuretics	Bendroflumethiazide, spironolactone, furosemide
2.5 Hypertension / heart failure	Ramipril, enalapril, losartan
2.8 Anticoagulants and protamine	Warfarin, rivaroxaban, edoxaban, apixaban, dabigatran
2.9 Antiplatelets	Clopidogrel, dipyridamole
4.1 Hypnotics and anxiolytics	Benzodiazepines, Z-drugs
4.2 Antipsychotic / antimanic drugs	Amisulpride, risperidone
4.3 Antidepressants	Amitriptyline, fluoxetine, paroxetine
4.7.2 Opioid analgesics	Tramadol, co-codamol, morphine, fentanyl
10.1 Rheumatic diseases and gout	NSAIDs, corticosteroids, methotrexate

The study concluded that while these drugs have proven benefit for patients, they still present a potential harm to the patient and measures should be put in place to reduce the burden of ADRs and further improve the benefit:harm ratio.

Coding for Review

When reviews are undertaken, in order to facilitate evaluation on the impact of polypharmacy reviews and patient outcomes, the reviews should be coded with the READ code 8B31B. This will ensure that as patients move across transitions of care there is continuity in the management of their medicines.

A polypharmacy review is a medication review following the principles of the 7 steps, that considers all the clinical information and where outcomes from the review are discussed with the patient and/or carer; either face to face or by telephone.