4/3/2020 Cocktail 10.1.1 Download
Polypharmacy – the concurrent use of multiple medications by one individual – is an increasingly common phenomenon that demands attention at clinical policy and practice level. Driven by the growth of an ageing population and the rising prevalence of multi-morbidity, polypharmacy has previously been considered something to avoid. It is now recognised as having both positive and negative potential, depending on how medicines and care are managed.This report proposes a pragmatic approach, offering the terms ‘appropriate’ and ‘problematic’ polypharmacy to help define when polypharmacy can be beneficial. Drawing on literature from predominantly Western countries, the report traces the occurrence of polypharmacy in primary and secondary care, and in care homes. It explores systems for managing polypharmacy and considers it in the context of multi-morbidity and older people, offering recommendations for improving care in both cases. Key findings.
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For many people, appropriate polypharmacy will extend life expectancy and improve quality of life. Their medicines use will be optimised and prescribed according to best evidence. In problematic polypharmacy there can be an increased risk of drug interactions and adverse drug reactions, together with impaired adherence to medication and quality of life for patients.
Many clinical trials and practice guidelines do not consider polypharmacy in the context of multi-morbidity. It is important that pragmatic clinical trials are conducted that include patients with multi-morbidity and polypharmacy.
Multi-morbidity and polypharmacy increase clinical workload, so doctors, nurses and pharmacists need to work coherently as a team with a balanced clinical skill-mix. People often do not take medicines as they are intended. I worry health care professionals work in silos & there are very few real concrete drivers to operate differently. A lot of trials exclusively looked at addressing errors at the point of prescribing (PRACtICe )or very intensive pharmacy led interventions (PINCER). While both are extremely laudable & excellent pieces of research & interventions, are they able to be scaled up?Is perhaps a more embedded multi-disciplinary approach not the (simpler) answer? Are the existing GP & Community Pharmacy (CP) contractual levers around medicines optimisation really used in a truly multi-disciplinary way?
Have commissioners (both local & national) missed a trick by not dove trailing & integrating the GP & CP contracts better, with patient outcomes as the main driver? (I specifically only mean in the context of Medicines Optimisation here, I accepted there are lots of other patient outcome focused items in the GP & CP contracts). I appreciated the recent contractual negotiations caused heated discussion in the GP profession, & a similar debate is going to hit the CP profession as that contract is negotiated, but I would propose a truly integrated multi-disciplinary primary care approach is the best lever to address medicines optimisation.Of course, the rather large elephant in the room is non-compliance, both unintentional and probably more importantly intentional non-compliance.
Addressing the latter is the QIPP Holy Grail but very little innovative commissioning seems to be directed at this.The following line seems a rather understated way to say something we should all be shouting about: Close collaboration of pharmacists and doctors in both prescribing and subsequent medication review seems a sensible approach (Holland et al 2005; Salter et al 2007). (I would have added Practice & Community Nurses, & indeed many others including formal & informal carers to the mix).There are lots of “call to action” documents being published at the moment, perhaps a “call to action” for us to climb out of our silos is needed? I've just organised a dosset box for mum-in-law after an impromptu medication review (at my request) at the end of a best interest meeting.
I'd attempted to figure out what in the mixed bag of medications was supposed to being been taken and when with a list beside me. It was very confusing.I work in health service research so know about 'medication reviews', 'concordance' and the availability of dosset boxes but I had to go and ask specifically about them and suggest we go for concordance over compliance.Perhaps there's something about letting patients and families know what they can ask for and for healthcare professionals to expect to be asked (would they have listened to my mum-in-law if she had been on her own without a 'professional' family member with her who knew the right jargon?)How do we get what we know into practice for everyone? Under practical tips ' Ensure that the directions on each prescription identify the problem it is intended to treat ' no advice is given on how to achieve this.
Primary care computer systems can easily add this to the drug use instructions. Visit clinicalindications.com. This is advocated in the latest GMC guidelines on prescribing.
We desperately need to move forward on this issue of polypharmacy and proper computerisation of clinical indications approach would help confused clinicians cope with the present avalanche of drug prescribing. Marina Buswell - While I can't comment on the specifics of your case, I find in my daily reviews of patients and their medication that those patients who have been put on a dosette box know little to nothing about their medication. They may very well be taking their medication but not understanding why they take each medicine leads to even poorer compliance. The danger of dosette boxes is that if a patient decides they don't like taking all those tablets they must stop all of them and not just the ones they really need.
Better patient education and an agreement between the patient and prescriber regarding which medicines they need to take would probably improve things no end.That said, it is convenient for carers/relatives etc to just pop the dosette box open and hand the tablets over. I believe that we are missing opportunities to help patients with multiple morbidities when they are admitted to any healthcare setting in taking the time to discuss medicines with the patient and careers and to address the issues before they are discharged back to primary care. My own experience with my family has shown me that there needs to be review of how pharmaceutical care is delivered in secondary care and the expected outcomes. There needs to be greater handover between secondary and primary care on discharge and connecting with the community pharmacists will be key in sustaining any improvements made.
AbstractIn the last 10 years, good evidence has become available to show that the combined effects of endocrine disruptors (EDs) belonging to the same category (e.g., estrogenic, antiandrogenic, or thyroid-disrupting agents) can be predicted by using dose addition. This is true for a variety of end points representing a wide range of organizational levels and biological complexity. Combinations of EDs are able to produce significant effect, even when each chemical is present at low doses that individually do not induce observable effects. However, comparatively little is known about mixtures composed of chemicals from different classes of EDs. Nevertheless, I argue that the accumulated evidence seriously undermines continuation with the customary chemical-by-chemical approach to risk assessment for EDs.
Instead, we should seriously consider group-wise regulation of classes of EDs. Great care should be taken to define such classes by using suitable similarity criteria. Criteria should focus on common effects, rather than common mechanisms. In this review I also highlight research needs and identify the lack of information about exposure scenarios as a knowledge gap that seriously hampers progress with ED risk assessment.
Future research should focus on investigating the effects of combinations of EDs from different categories, with considerable emphasis on elucidating mechanisms. This strategy may lead to better-defined criteria for grouping EDs for regulatory purposes. Also, steps should be taken to develop dedicated mixtures exposure assessment for EDs. Key words: combination effect, combined exposure, endocrine-disrupting chemical, mixture, review. Environ Health Perspect 115(suppl 1):98–105 (2007). Doi:10.1289/ehp.9357 available via.
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