A case of polypharmacy – “I’ll be rattling if I take all these doctor!”

Brian is an 81 years old man who books a GP appointment to discuss knee pain. He is requesting some stronger analgesics as his current medications, including co-codamol 30/500 and amitriptyline aren’t helping.

You determine he has had knee pain for over 20 years. He has attended physiotherapy sessions and has had two steroid injections which just provided short term pain relief. He has declined knee replacement surgery as he lives alone and has a dog that he needs to take care of. His wife died suddenly three years ago. He likes to maintain his independence.

Past Medical History

• Hypertension
• Type 2 diabetes
• Osteoarthritis
• Overactive bladder
• Depression
• Gout
• Dry eye syndrome
• Constipation

Medication

• Ramipril
• Indapamide
• Metformin
• Amitriptyline
• Co-codamol 30/500
• Oxybutynin
• Allopurinol
• Citalopram
• Systane eye drops
• Fybogel
• Atorvastatin

He is eager for a stronger analgesic, preferably a butrans patch, like his neighbour uses for their joint pain. He hopes this will enable him to keep up with his regular dog walks. He also remarks that he’s tired of taking so many different medications and wonders if he needs to be on so many.

You determine he would benefit from a medication review, including a discussion of chronic pain management.

Brian is a common case you may encounter in everyday practice. In the following sections, we’ll consider how to approach a case of polypharmacy, initially by reflecting on the adverse outcomes linked to polypharmacy, hence why this area is such a priority in our current practice.