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OKA813 NP176 News 13 stew 22/11/00 12:07 PM Page 3
National Prescribing Service Newsletter
ISSN 1441-7421 December 00
What is polypharmacy?
Polypharmacy is the concurrent use of multiple medications. It can be associated with the prescription
and use of too many or unnecessary medicines at dosages or frequencies higher than therapeutically
essential. However, multiple medications are often necessary and can constitute best care for patients.
The most recent National Health Survey (1995) found that 10.7 million (59.1%) Australians weretaking prescribed or over-the-counter medications (excluding complementary medicines). Of these asubstantial proportion were using multiple medications (Table 1).
Table 1. Proportion of higher users of medications (as a percentage of those taking at least one medication*)
Number of medications
under 65 years
over 85 years
*Excludes complementary medicines (vitamins, herbal preparations, etc).
Elderly patients at increased risk
Older people have higher rates of chronic illness and are more likely to be taking multiple medications.
Polypharmacy increases the risk of adverse drug events such as falls,1 confusion and functional decline.2
Changes in physiology and social and physical circumstances contribute to the risk of adverse drug events.
Older people are more likely to experience poor vision, hearing and memory loss and have altered metabolic
rates, such as declining renal function.
Adverse reactions may go undetected because symptoms may mimic problems associated with older age such as forgetfulness, weakness or tremor. Adverse reactions may also be misinterpreted as a medicalcondition and lead to the prescription of additional drugs.
National Prescribing Service Limited ACN 082 034 393
– an independent, non-profit, educational organisation supporting quality prescribing in Australia.
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A case in point
This case highlights some of the problems that can arise with polypharmacy. The patient described
needed significant changes to her medication. While this is not typical of every medication review,
it is taken from an actual case.
Medications at time of review:
Sertraline (Zoloft®) 50mg in the morning
Gliclazide (Diamicron®) 80mg in the morning
Metformin (Diabex®) 500mg three times daily
close to her daughter but at some distance
Isosorbide mononitrate CR (Imdur Durule®) 60mg daily
Propantheline (Pro-Banthine®) 15mg dailyNaproxen (Naprosyn®) 500mg suppository at night
diabetes mellitus, recurrent urinary tract
infections, osteoporosis, osteoarthritis and
incontinence and fractured her right femur
Note: Brands specified are those used in this actual case.
Other brands are available for some drugs (refer to listof drugs).
Most of Mrs Jones’ medications are essential to
Propantheline - appropriateness of therapy:
her care. Her diabetes and cardiovascular
Propantheline is an anticholinergic agent
disease are well controlled and no changes
that relaxes the detrusor muscle to treat urinary
to these medications are considered necessary.
urge incontinence. It can cause confusion and
constipation in elderly patients. Further
discussion with Mrs Jones reveal that since
investigation finds that Mrs Jones suffers from
starting sertraline about four months ago,
stress incontinence and so propantheline is
she has felt much ‘brighter’. However, the GP
ceased and the nursing staff institute alternative
and pharmacist identify several medications that
toileting techniques. Ongoing need for laxative
therapy will be reviewed at the next visit.
Hexamine hippurate - drug interaction
Naproxen - appropriateness of therapy:
and inadequate dose:
Rectal delivery of naproxen does not reduce the
is a urinary antibacterial requiring a urinary pH
risk of gastrointestinal ulceration, although it
< 5.5 for activity and a dose of 1g twice daily.
may reduce the incidence of dyspepsia. The GP
Concurrent use of the urinary alkaliniser, Ural®
decides to trial paracetamol at a dose of 1g four
is senseless. Hexamine hippurate will not be
times daily and use naproxen on an intermittent
effective where infection is due to Proteus
basis when Mrs Jones’ osteoarthritis symptoms
species, since these also
increase urinary pH. The GP decides to ceasethe hexamine hippurate and trial a prophylactic
Alendronate - patient (and carer) education:
The pharmacist and GP remind the patient and
nursing home staff about the appropriate
but at a later review will be ceased.
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administration of alendronate, ie with a full glass
Benzodiazepines - ongoing need:
Regular use of
of water, while sitting in an upright position.
benzodiazepines is reviewed. The GP decides tocontinue the oxazepam until Mrs Jones becomes
Omeprazole - ongoing need:
The GP and
more settled in her new environment and will
pharmacist question the indication for omeprazole
consider a withdrawal regimen at the next visit.
therapy, which is not clear from the medicalhistory. The question of whether omeprazole
Mrs Jones’ new medication regimen remains
was initiated to treat NSAID or alendronate
extensive, however unnecessary and inappropriate
induced gastrointestinal pain/dyspepsia will be
medications will be reviewed in follow up visits.
Steps for managing polypharmacy
Avoid prescribing for minor, non-specific or self-limitingcomplaints. Only prescribe when there is good evidence oflikely efficacy as well as a strong need for the medication.
An accurate drug history is essential for patients on multiplemedicines. This is best achieved when the medication review is done in the patient’s home. Alternatively ask the patient to bring in all their medicines (prescribed and non-prescribed). A review includes assessing appropriateness and ongoing needfor therapy, adverse effects and interactions, the dosage regimeand formulations, and also compliance.
Use lifestyle measures whenever possible either as an adjunct or instead of medications.
Talk with the patient about their concerns, expectations,difficulties in using the medications and their ability to followthe medication regimen. Discuss changes to the medicationregimen with the patient’s other health care providers.
Reduce the regimen to essential drugs. Consider fewest possibledosage intervals and dose reduction where appropriate. Limituse of optional, trivial and placebo medications.
Table 2. Common examples
Reason for reassessment
controlled with ACEinhibitor and diuretic
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Prescribing pointers -
▲ Any medication should be started as a trial and discontinued if ineffective or if side effects are
▲ Retain only those medicines for which there is an ongoing need. Decrease the dosing frequency
and titrate doses down where appropriate.
▲ The patient needs to be a responsible partner and fully understand the rationale for ceasing
▲ Be aware that discontinuation of drug therapy can be associated with adverse drug withdrawal
events in some cases. Medications commonly associated with adverse events unless the dose istapered include beta-blockers, sedatives, hypnotics, opiates, antidepressants, antipsychotics andcorticosteroids.
Your questions answered
Following is a question from the nursing staff that arose after Mrs Jones’ medication review (see page 2).
Could the antibiotic for prevention of urinary tract infection (UTI) be replaced with cranberry juice?
Cranberries, particularly in the form of cranberry juice, have been used widely for several decadesfor the prevention of urinary tract infections. A Cochrane review,3 published in 1998, found fourtrials of reasonable design (three cross-over, one parallel group) to include in the review. Two ofthe studies of prevention of UTI in elderly patients found that cranberry was more effective thanplacebo in some patients.4,5
However, these studies were small with high withdrawal rates and lack of ‘intention to treat’analysis. This may mean that effectiveness of cranberry juice was overestimated. The large numberof dropouts from the trials indicates that cranberry juice may not be acceptable to patients overlong periods of time. In Mrs Jones’ case a trial of cranberry juice would do no harm but herprophylactic antibiotic should probably also be continued.
The NPS Therapeutic Advice and Information Service (TAIS) provides health professionals withinformation on therapeutics. Telephone TAIS on 1300 138 677 to ask your questions.
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From the Therapeutic Goods Administration (TGA)
and Pharmaceutical Benefits Advisory Committee (PBAC)
Both cisapride (Prepulsid®, Prepulsid Forte®) and thioridazine (Aldazine®
prolonged QT intervals with the possibility of rare but serious and sometimes fatal cardiacarrhythmias. The approved indications and the listing of these drugs in the PBS schedule have changed in light of these safety concerns.
The approved indication for cisapride for use in adults has been amended to:
▲ treatment of severe reflux oesophagitis where other available treatment including acid
suppression with proton pump inhibitor drugs has failed
▲ treatment of gastroparesis where the diagnosis has been made or confirmed by a specialist
The approved indication for cisapride for use in children has been amended to:
▲ severe, proven gastro-oesophageal reflux.
The PBS listing for cisapride has changed to an authority listing for:
▲ treatment of gastroparesis where the diagnosis has been made or confirmed by a consultant
In the absence of clinical data in patients who have not responded to the proton pump inhibitorsin the treatment of reflux oesophagitis, the PBAC does not support the continued subsidy listing of cisapride for this group of patients.
The approved indication for thioridazine has been amended and it is now restricted to anauthority listing on the PBS for:
▲ the management of schizophrenic patients who have failed to respond adequately to treatment
with appropriate courses of at least two other antipsychotic drugs, at an adequate dose and for an adequate duration, either because of insufficient effectiveness or the inability to achieve an effective dose due to intolerable adverse effects from those drugs.
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NPS Pharmacy program
In December, the NPS will be increasing the range of activities available to pharmacists by sending outthe first Pharmacy Clinical Audit on over-the-counter NSAIDs. This initiative will be the first of manytopic-based activities developed specifically for community pharmacists.
The NSAIDs audit will provide community pharmacists with a tool to check their current practice forsupply of these medications. The audit on NSAIDs contains a step-by-step guide for pharmacists and non-pharmacist staff when either a patient requests an over-the-counter NSAID, or presents with symptomswhere NSAIDs may be indicated. For more information please contact the NPS on 02 9699 4499.
NOTE: There was a typographical error on page 1 of NPS News 11
on Depression. The juxtaposition of the text made it appear
that moclobemide, nefazodone and venlafaxine are SSRIs. We would like to clarify that this is not the case.
For details on the contributing authors and reviewers and any declarations of interest please contact NPS on 02 9699 4499.
3. Jepson RG, Mihaljevic L, Craig J.
polypharmacy and drug misuse in the elderly. Clin Geriat Med1992;8:143-58.
The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence.
Any treatment decisions based on this information should be made
in the context of the individual clinical circumstances of each patient.
To improve health outcomes for Australians through prescribing that is : ▲ safe ▲ effective ▲ cost - effective
To enable prescribers to make the best prescribing decisions for their patients, the NPS provides:
▲ information ▲ education ▲ support ▲ resources
Level 1 / 31 Buckingham Street, Surry Hills NSW 2010
Phone: 02 9699 4499 l Fax: 02 9699 5155 l email: email@example.com l net: http://www.nps.org.au
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N P S Case study 12: Polypharmacy
You are invited to submit your responses to the following case for collation. We will return a copy of the aggregated responses that willprovide a snapshot of how your colleagues responded to the case and comments from an expert in the field. This case study is eligible forinclusion in the Practice Incentives Program (PIP) program for GPs.
PLEASE COMPLETE CLEARLY IN BALL POINT PEN, BLOCK LETTERS ONLY
Send completed case study 12 to: National Prescribing Service, 1/31 Buckingham Street, Surry Hills NSW 2010 or
fax to 02 9699 5155. Submission date: 12 January 2001.
David is a 74 year old who lives on his own at home. Lately he has been having difficulty walking to the shops and has to stop frequentlyto catch his breath. He has suffered from angina for five years. Heart failure of moderate severity was diagnosed in 1997, when enalaprilwas prescribed. During a hospital admission in 1998, ventricular arrhythmias were noted on ECG, and amiodarone was added to theregimen. His other main complaint is osteoarthritis. He takes piroxicam for the pain in his knees and wrist, which was broken six monthsago. He feels depressed and sleeps poorly. His current medications are:
Drug name and dose
Drug name and dose
*Dose started at 40mg daily and increased over three years
1. Do you identify any of the following?
2. What action would you take?
(please tick and specify actions)
(please tick and specify drug and problems identified)
□ Drug-drug interaction:__________________________________________
□ Add a medication: ________________________________________
□ Drug-disease interaction:___________________________________
□ Cease a medication:_______________________________________
□ Contraindication for one (or more) of the drugs: ________________
□ Increase dose of: _________________________________________
□ Evidence of an adverse drug event/side effect of a drug:__________
□ Reduce dose of: __________________________________________
□ Need for review of appropriateness of drug selection: ___________
□ Substitute an alternative medication for:_____________________________
□ Need for review of dose/frequency: __________________________
□ Discuss medication regimen with patient:____________________________
□ Concordance/compliance problem: ___________________________
□ Discuss side effects with patient: ____________________________
□ Need for investigations:____________________________________
□ Other: __________________________________________________
□ Other: ________________________________________________________
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