What steps should be taken to manage a patient on polypharmacy (multiple medications) for non-communicable diseases (NCDs)?

Systematic Approach to Managing Polypharmacy in NCD Patients

A comprehensive medication review should be performed at least annually for all patients on multiple medications for non-communicable diseases to optimize therapy, reduce adverse events, and improve outcomes. 1

Step 1: Medication Reconciliation and Assessment

• Create an accurate medication list including all prescriptions, over-the-counter medications, supplements, and herbal remedies to identify discontinued, missing, or incorrectly taken medications 2, 1
• Document all known diagnoses, conditions, existing laboratory results, and medication-related problems in the electronic medical record 2
• Use validated tools like the Morisky Medication Adherence Scale to identify adherence barriers and review pill boxes, medication bottles, and fill dates 2, 1
• Assess medication administration difficulties, treatment burden, and patient's ability to manage their regimen 2

Step 2: Interaction Assessment

• Evaluate potential drug-drug interactions using interaction databases, paying particular attention to QT prolongation risks, anticoagulant interactions, and serotonin syndrome potential 2, 1
• Identify medications that may worsen existing conditions (drug-disease interactions), such as NSAIDs in heart failure, chronic kidney disease, or hypertension 2
• Look for duplicate therapies or medications with additive side effects that could result in toxicity 2, 1
• Assess for prescribing cascades where medications are added to treat side effects of other medications 2

Step 3: High-Risk Medication Identification

• Use validated tools like Beers Criteria or STOPP/START to identify potentially inappropriate medications in older adults 2, 1
• Pay special attention to high-risk drug classes including sedatives/hypnotics, opioids, anticholinergics, benzodiazepines, anxiolytics, and hypoglycemics 2
• Evaluate the risk-benefit ratio of each medication, considering the patient's age, renal function, and other comorbidities 2
• Adjust doses based on declining kidney function using laboratory-reported clearance estimates 1

Step 4: Patient Preferences and Goal Setting

• Discuss with the patient the purpose of medication optimization to improve quality of life and function 2
• Encourage patients to express their personal values, aims, and priorities regarding treatment 2
• Establish disease and treatment burden, including effects on daily life, mental health, general wellbeing, and quality of life 2
• Involve family members or caregivers in the assessment process when appropriate 2

Step 5: Deprescribing When Appropriate

• Target medications from which patients no longer derive reasonable benefit 2
• Consider deprescribing when potential harm outweighs benefit, including education about risks for patients and families 1
• Implement gradual tapering of high-risk medications rather than abrupt discontinuation 1
• Monitor for withdrawal symptoms or disease recurrence after medication discontinuation 2, 3

Step 6: Monitoring and Follow-Up

• Schedule regular follow-up appointments to assess medication effectiveness and adverse effects 2
• Increase monitoring frequency during care transitions (hospital admission, transfers between wards, discharge) 2
• Coordinate care among multiple prescribers to prevent duplication and ensure medication appropriateness 1
• Document changes to the medication regimen and communicate these to all healthcare providers involved in the patient's care 2

Common Pitfalls to Avoid

• Focusing only on the number of medications rather than their appropriateness 1
• Overlooking non-prescription medications and supplements in the assessment 1, 4
• Failing to consider patient preferences and treatment goals when optimizing medications 1
• Neglecting to monitor for adverse effects or disease recurrence after medication changes 3
• Inadequate communication between multiple healthcare providers leading to uncoordinated care 2

Special Considerations for NCD Management

• Assess the management of chronic pain, depression, anxiety, and other common comorbidities 2
• Evaluate physiological and functional status, nutritional and hydration requirements 2
• Consider using a multidisciplinary team approach, especially involving clinical pharmacists when available 1
• Utilize computerized alerts and decision support tools when possible to improve medication management 1, 5