Seven steps to appropriate polypharmacy

An expert generalist conducting a medication review would likely have two main steps to their approach.:

1. To identify a list of health problems, taking time to consider why a person would potentially need medication to manage these and what factors could influence tailored decision making.
2. Check the patient’s medication list, reviewing what they take and why.

The Scottish prescribing guidelines outline a more detailed 7 step approach to appropriate polypharmacy. These steps encourage the clinician to gather data to support shared decision making, think smartly about prescribing and balance burdens against benefits.

The burden of treatment for many people with chronic, complex co-morbidities reduces their capacity to collaborate in their care.

Therefore, reducing treatment burden and polypharmacy could facilitate patient involvement in medication reviews and collaboration with care decisions.

Put simply, the 7 steps involve:

Figure 1: 7 Steps to Appropriate Polypharmacy

A more detailed overview of the 7 steps to appropriate polypharmacy can be found here.

So let’s return to the case of Brian and consider how the 7 steps to appropriate polypharmacy would look when applied to his case…

On review of Brian’s medical records, you note he recently attended a nurse-led annual review.

• He was advised about weight loss (BMI 31)
• His blood pressure was within the normal range (132/78mmhg)
• His recent blood tests showed a HBA1c of 49 (stable) and cholesterol of 3.4 (stable)

When you talk to Brian about his priorities for the medication review, he shares the following thoughts that could help your decision making (a reminder of his medications/ past medical history are at the end of this step).

Brian feels he’s “rattling” he takes so many pills, so is keen to reduce his list of medicines. He tells you he’s keen to stay on his cholesterol pill after his brother died last year of a heart attack.

His brother had prostate cancer before he died which is why Brian recently asked to have his PSA checked. His GP also recently did a PR exam which was normal. However, he reports ongoing problems with urgency of micturition and occasional incontinence. He wonders if his treatment for this needs changing, recounting that his previous tablet, solifenacin, didn’t help either.

He reports struggling to manage with the pain in his knee. The co-codamol just takes the edge off his pain whilst his constipation has been worse, which is getting him down, so he is keen to change these to something else. He tells you he stopped his citalopram a few months ago as he didn’t feel they were doing anything. He also adds that his gout has been flaring up more lately. Otherwise he feels his health conditions are generally well controlled.

Over to you

Apply the 7 steps of appropriate polypharmacy to Brian’s medication regime.

There is no list of perfect answers, but if you follow the 7 steps you can negotiate a plan that Brian is happy with and that you can clinically defend. Join in the conversation below and share what main changes you think you would agree to make with Brian…

An example of how you might apply the 7 steps is available as a PDF link at the end of this discussion.

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