Polypharmacy in diabetes

See the section on polypharmacy in diabetes for further information.

This NTI highlights individuals prescribed three or more categories of anti-diabetic drugs. These patients may also be prescribed additional medication for other co-morbidities, further increasing the risks associated with polypharmacy.

Polypharmacy can be appropriate, ensuring that people with diabetes achieve target HbA1c levels.
Polypharmacy can also be inappropriate either:
- due to over treatment, e.g., increasing risks of hypoglycaemia and falls
- ineffective polypharmacy resulting in increased risks of adverse effects, but no benefit in treatment outcomes.
The various categories of anti-diabetic medication have differing effects on glycaemic control and therefore those less effective in achieving the target HbA1c should be reviewed.
Polypharmacy increases the risk of Adverse Drug Reactions.
The 7 Steps medication review process should be used during medicine reviews.
Prescribers should work with patients to develop an understanding of the importance of self-management and the successful achievement of goals. This will include aspects such as medication sick day guidance and lifestyle changes.

Action required by boards/clusters/practices

It is currently possible to identify people on triple therapy in GP practice and it is recognised that many people with T2DM will require triple therapy for disease control. However, the risks associated with this increase with age/frailty and comorbidity.
GP clusters and practices can review their data with others in the board and consider what quality improvement projects may be suitable, based on available data.
Identify individuals who are
- prescribed more anti-diabetic medication than required to meet target glycaemic control and reduce therapy.
- safety issue: no evidence to support co-prescribing of DPP-4i/gliptins and GLP-1RA and this should be avoided. Action to stop gliptin.
- within target HbA1c range but prescribed medication with less efficacy – stop less/ineffective therapies.
- not at target HbA1c despite polypharmacy. Action change in therapy to achieve target glycaemic control, especially less efficacious medication. Prioritise younger individuals for more aggressive treatment.
- prescribed selected anti-diabetic medication less suitable/contra-indicated for co-morbidities and prescribe suitable alternative.
Boards should review formulary treatment algorithms.
Utilise clinical decision support tools to aid prescribers in treatment choices including Right Decisions Service app/website
People with dual diagnosis of T2DM, depression and poor glycaemic control.