Managing Polypharmacy in the UK: A Pharmacist’s Guide to Safer Prescribing

The rising tide of polypharmacy represents one of the most significant challenges in modern healthcare. For pharmacists across the United Kingdom, moving from dispenser to clinical decision-maker is no longer an aspiration but a necessity. This guide offers a framework for pharmacists to confidently and effectively manage polypharmacy, ensuring safer, more personalised prescribing for every patient.

Polypharmacy, typically defined as the concurrent use of five or more medicines, is not inherently negative. "Appropriate polypharmacy," where multiple medicines are used according to best evidence to manage complex conditions, is often essential. The danger lies in "problematic polypharmacy," where the risks of a patient's medication regimen outweigh the benefits, leading to a heightened risk of adverse drug reactions (ADRs), non-adherence, hospital admissions, and a diminished quality of life.

In the UK, the NHS is placing a significant emphasis on tackling this issue, with pharmacists in Primary Care Networks (PCNs), community pharmacies, and hospitals playing the central role. The key to success is the Structured Medication Review (SMR), a comprehensive, patient-centred consultation that moves beyond a simple clinical check to a holistic evaluation of a patient's health and goals.

The Pharmacist's Mandate: Leading the Charge on Polypharmacy

Pharmacists are uniquely positioned to manage polypharmacy due to their deep pharmacological knowledge and regular patient contact. The role encompasses several key functions:

• Identifying High-Risk Patients: Proactively using data and clinical judgment to find patients who would benefit most from a review.

• Conducting Comprehensive Medication Reviews: Utilising a systematic approach to assess the appropriateness, safety, and efficacy of each medicine.

• Facilitating Shared Decision-Making: Engaging patients in a meaningful dialogue about their medicines, ensuring treatment aligns with their personal goals.

• Deprescribing: Having the confidence and competence to initiate the process of stopping or reducing medicines that are no longer providing benefit or are causing harm.

• Collaborating within Multidisciplinary Teams (MDTs): Working closely with GPs, nurses, and other healthcare professionals to ensure a cohesive approach to patient care.

  
  

A Practical Framework: The 7-Step Medication Review

Adopted by NHS Scotland and widely endorsed, the 7-Step medication review process provides a robust and patient-centric framework for conducting an SMR.

Step 1: What matters to the patient? (The Aim)

This is the most crucial step. The conversation must begin with the patient's perspective.

• Key Questions: "What are you hoping to get from your medicines?", "What does a good day look like for you?", "Are you having any problems with your medicines that worry you?"

• Goal: To establish the patient's health priorities, treatment objectives, and personal values. This sets the context for all subsequent decisions.

  
  

Step 2: Identify essential drug therapy

Which medicines are critical and should not be stopped without specialist advice?

• Examples: Levothyroxine for hypothyroidism, anti-epileptics, insulin for Type 1 diabetes, or drugs for Parkinson's disease.

• Action: Mentally flag these medicines as having a high threshold for change.

Step 3: Does the patient take unnecessary drug therapy?

Scrutinise each remaining medicine for its ongoing indication and benefit.

• Consider:

  • Medicines for a temporary indication (e.g., a PPI started during a hospital stay).

  • Medications where the evidence for benefit is limited in that specific patient (e.g., a statin for primary prevention in a frail, elderly patient with limited life expectancy).

  • Higher than necessary maintenance doses.

    
    

Step 4: Are therapeutic objectives being achieved? (Effectiveness)

Is the medicine actually working and meeting the goals agreed in Step 1?

• Action: Check clinical parameters (e.g., blood pressure, HbA1c) and patient-reported outcomes (e.g., pain scores, symptom control).¹¹ If a medicine isn't effective, it may be unnecessary.

  
  

Step 5: Is the patient at risk of ADRs? (Safety)

This is the pharmacist's heartland. Proactively identify potential and actual harm.

• Key Areas of Focus:

  • High-Risk Combinations:

    • The "Triple Whammy": An ACE inhibitor/ARB + a diuretic + an NSAID. This combination significantly increases the risk of acute kidney injury.

    • Anticholinergic Burden: Accumulation of drugs with anticholinergic properties (e.g., amitriptyline, oxybutynin, older antihistamines) leading to confusion, falls, and constipation.

    • Serotonin Syndrome Risk: Concurrent use of multiple serotonergic agents (e.g., SSRIs, tramadol, triptans).

  • Drug-Disease Interactions: For example, prescribing a beta-blocker to a patient with asthma.

  • Monitoring: Ensure appropriate monitoring is in place for high-risk drugs like warfarin, lithium, or methotrexate.

  • "Sick Day Rules": Does the patient know which medicines (e.g., metformin, ACE inhibitors, diuretics) to temporarily stop if they become unwell with vomiting or diarrhoea?

    
    

Step 6: Is drug therapy cost-effective and environmentally sustainable?

While clinical factors are paramount, resource stewardship is also important.

• Action: Consider if a more cost-effective, clinically appropriate alternative exists. Also, consider the environmental impact, such as switching to lower-carbon inhalers where clinically suitable.

  
  

Step 7: Is the patient willing and able to take the medicines as intended? (Patient-centredness)

This final step ensures the plan is practical and aligned with the patient's wishes.

• Consider: Can the patient swallow the tablets? Is the dosing schedule manageable? Does the patient believe in the treatment?

• Tool: Use the "teach-back" method to confirm the patient understands the plan.

  
  

Tools of the Trade: Aiding Clinical Decisions

To support the 7-Step process, several evidence-based tools are invaluable:

• STOPP/START Criteria: (Screening Tool of Older People's Prescriptions / Screening Tool to Alert to Right Treatment). This is a widely used, validated tool that lists potentially inappropriate medicines in older people (STOPP) and common prescribing omissions (START). It is an excellent aid for Step 3 and Step 5 of the review.

• NHS BSA Polypharmacy Comparators (ePACT2): This data tool allows PCN and practice pharmacists to benchmark their prescribing against national averages. It can help identify patients on 10+ medicines or those prescribed high-risk combinations, enabling targeted invitations for an SMR.

• Anticholinergic Burden Calculators: Online tools and apps can quickly calculate a patient's total anticholinergic burden, helping to quantify the risk of cognitive impairment and falls.

The Art of Deprescribing: Communication is Key

Deprescribing can be daunting for both clinicians and patients who may feel that stopping a medicine is "giving up." Effective communication is crucial for building trust and achieving a shared agreement.

The FRAME model offers a useful approach:

• Fortify the relationship: Build trust and rapport first.

• Recognise patient willingness: Ask open questions like, "How do you feel about the number of medicines you are taking?"

• Align with patient goals: Link the deprescribing recommendation to what matters to them. For example, "You mentioned you want to avoid falls. One of your tablets can cause dizziness, and I think we should look at safely reducing it."

• Manage cognitive dissonance: Acknowledge that they were previously told the medicine was essential. Explain that health needs change over time and that regular reviews ensure their medicines remain right for them now.

• Empower the patient: Reassure them that deprescribing is a trial. Agree on a monitoring plan and let them know who to contact if they feel unwell, ensuring a safety net.

Overcoming the Challenges

Implementing effective polypharmacy management is not without its hurdles:

• Time Constraints: SMRs require dedicated, protected time (a minimum of 30 minutes per review is recommended).

• Lack of Data Access: Community pharmacists may lack access to the full patient record, making a comprehensive review challenging.

• Prescriber Resistance: Some prescribers may be hesitant to accept deprescribing recommendations. Clear, evidence-based communication is vital.

• Patient Reluctance: Patients may be attached to long-term medicines. The communication strategies outlined above are essential to overcome this.

Conclusion: The Future is Pharmacist-Led

Managing polypharmacy is a defining professional activity for pharmacists in the UK. It is the practical application of medicines optimisation, blending deep clinical knowledge with patient-centred communication. By adopting a systematic approach like the 7-Steps, utilising evidence-based tools, and mastering the art of shared decision-making, pharmacists can lead the way in reducing medication-related harm, improving patient outcomes, and ensuring that every prescription is a truly safe and effective one.