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Appropriate Long Term Prescribing and Polypharmacy

Appropriate Long Term Prescribing and Polypharmacy. Alpana Mair Dr Gregor Smith. Some Background: The ageing population. 62% projected rise in over 65s 2006-31 144% projected rise in over 85s 2006-31 Increased prevalence of LTC, esp COPD and Diabetes

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Appropriate Long Term Prescribing and Polypharmacy

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  1. Appropriate Long Term Prescribing and Polypharmacy Alpana Mair Dr Gregor Smith

  2. Some Background: The ageing population • 62% projected rise in over 65s 2006-31 • 144% projected rise in over 85s 2006-31 • Increased prevalence of LTC, esp COPD and Diabetes • 24% projected rise in older people admitted as emergencies by 2016 • Would require an extra £3.5 billion 2031 Audit Scotland

  3. Multiple Morbidities • “Multiple conditions”: presence of 2 or more LTC • Largely the norm but associated with poorer outcomes • More people in Scotland with MM below 65 years than above • Develops around 10 years earlier in deprived areas • Associated with more medical errors

  4. Multimorbidity in Scotland Mercer, Guthrie, Wyke: Scottish School of Primary Care

  5. Most people with any long term condition have multiple conditions in Scotland Mercer, Guthrie, Wyke: Scottish School of Primary Care

  6. Mercer, Guthrie, Wyke: Scottish School of Primary Care

  7. Pr. Bruce Guthrie, Dundee

  8. Pr. Bruce Guthrie, Dundee

  9. Contributory Factors • AGE • Non age factors that contribute to developing polypharmacy include: • Multiple morbidities • Residence in long term care home • Hospitalisation, esp repeat episodes of care • Patient expectation • GP attitude • Consultation with several doctors

  10. Polypharmacy: associated dangers • Adverse drug event • Confusion • Falls • Interactions • Drug – drug Interaction • Drug – Disease Interaction • Poor compliance and concordance

  11. Drugs commonly associated with admissions due to ADR • NSAIDs 29.6% • Diuretics 27.3% • Warfarin 10.5% • ACE 7.7% • Antidepressants 7.1% • Beta blockers 6.8% • Opiates 6.0% • Digoxin 2.9% • Prednisolone 2.5% • Clopidogrel 2.4%

  12. High Risk Combinations • NSAID plus any of: • ACE or ARB + diuretic (triple whammy) • eGFR <60 • Diagnosis heart failure • Warfarin • Age >75 without PPI

  13. High Risk Combinations • Warfarin Plus any of: • Another antiplatelet • NSAID • Macrolide • Quinolone • Metronidazole • Azole antifungal

  14. High Risk Combinations • Heart Failure diagnosis plus any of: • Glitazone • NSAID • Tricyclic antidepressant

  15. Drugs Poorly Tolerated in the Elderly • Digoxin (doses higher than 250mcg) • Antipsychotics • Tricyclic antidepressants • Benzodiazepines • Anti cholinergics • Phenothiazines • Combination painkillers

  16. Special considerations • Orthostatic hypotension • Shared side effects eg sedation, bleeding • Diabetic treatment; optimal HbA1c • Antipsychotic medication • Laxatives • Shortened life expectancy

  17. Drugs which can be associated with rapid symptomatic decline if stopped • ACE inhibitors in heart failure / LVSD • Diuretics in heart failure • Steroids • Drugs for heart rate or rhythm control • Anticonvulsants for epilepsy • Antidepressant, antipsychotic, mood stabilisers • amiodarone • Drugs for managing Parkinson’s Dis • Disease modifying anti-rheumatic drugs With caution With specialist advice

  18. CEL 36: November 2012 • Appropriateness of long term prescribing • At medicines review • On starting new medicines • First iteration of National Guidance • Aim – to improve therapeutic care by reducing the risk of adverse drug reactions associated with polypharmacy

  19. GMS Contract 2013 / 14 • Unique negotiated settlement in Scotland • QPQOF – High Risk Patients • Anticipatory Care Plans • Polypharmacy Review • Multi-disciplinary approach • SPARRA risk score 40-60% • 0.75% practice popn 1st yr, rising to 1.5% 2nd yr

  20. Questions? Dr Gregor Smith Alpana Mair

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