Best Practice Medication Management in Patients with Multiple Chronic Conditions
Comprehensive medication management delivered by a clinical pharmacist working collaboratively with the healthcare team is the standard of care for patients with multimorbidity and polypharmacy, ensuring each medication is appropriate, effective, safe, and able to be taken as intended. 1
Core Principles of Medication Management
Individualized Assessment and Optimization
Every medication must be individually assessed across four domains: appropriateness for the patient's conditions, effectiveness for the medical condition, safety given comorbidities and concurrent medications, and the patient's ability to take it as intended. 1 This approach has demonstrated improvements in medication adherence, clinical parameters (diabetes control, blood pressure), patient satisfaction, reduced hospitalizations, and cost savings. 1
Optimize treatment benefits over potential harms in both pharmaceutical and non-pharmaceutical interventions, particularly in elderly patients where medications like statins and bisphosphonates may only benefit those with estimated survival greater than five years. 1
Consider renal function for all medication dosing decisions: Use validated eGFR equations based on serum creatinine for most clinical settings, but employ more precise methods (combined creatinine-cystatin C equations or measured GFR) for drugs with narrow therapeutic windows. 1
Monitor eGFR, electrolytes, and therapeutic medication levels in patients receiving medications with narrow therapeutic windows, potential adverse effects, or nephrotoxicity, both in outpatient and hospital settings. 1
Medication Plan Development
Create an individualized patient-held medication plan that includes: specific drug information, exact usage instructions, "as needed" dosing with precise indication and individual dosage (single dose, interval, maximal daily dosage), prospective end dates for short-term prescriptions, and medication history including reduced renal function when indicated. 1
Select a primary pharmacy to coordinate self-administered drugs regarding dosage instructions and overall medication regimens, particularly when multiple prescribers are involved. 1
Review and limit over-the-counter medicines and dietary/herbal remedies that may be harmful, as patients with chronic conditions are more susceptible to nephrotoxic and adverse medication effects. 1
Systematic Medication Review Process
Regular Monitoring and Follow-Up
Review and update medication/care plans regularly to recognize and record changes in needs, with specific attention to: 1
Treatment effects and clinical parameters at follow-up appointments, checking for nonspecific symptoms as potential indicators of complications (dry mouth, weakness/fatigue, drowsiness, reduced alertness, sleep disturbances, motor disorders, tremors, falls, constipation, diarrhea, incontinence, loss of appetite, nausea, skin rashes, itching, depression, confusion, hallucinations, fear, agitation, vertigo, tinnitus). 1
Post-discharge monitoring: Newly introduced medications may not have reached steady state at discharge (typically requires 4-5 half-lives), so effectiveness and side effects cannot be properly assessed during short hospital stays. 1
Ongoing treatment demonstrations including medication administration techniques (e.g., inhalers) and effective self-monitoring forms. 1
Medication Regimen Optimization
Simplify medication regimens by: 1
Using long-acting drugs requiring once-daily dosing (preferably drugs with inherent pharmacokinetic properties rather than galenic formulation). 1
Prescribing fixed-dose single-pill combinations whenever feasible to improve adherence. 1
Avoiding complex dosing schedules. 1
Identifying and eliminating drug-related adverse events, ensuring appropriate dosing levels, and addressing duplication in therapy. 2
Hypertension Management in Multimorbidity
Initial Pharmacological Approach
For confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy as first-line treatment with a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic. 1
Exceptions requiring monotherapy consideration: patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (120-139/70-89 mmHg) with a compelling indication for treatment. 1
Starting dose for losartan: 50 mg once daily for most adults, with dose adjustment to maximum 100 mg daily as needed; use 25 mg starting dose in patients with possible intravascular depletion (e.g., on diuretic therapy). 3
For patients with hepatic impairment: Start losartan at 25 mg once daily for mild-to-moderate impairment; losartan has not been studied in severe hepatic impairment. 3
Escalation Strategy
If BP not controlled with two-drug combination: Increase to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as single-pill combination. 1
If BP not controlled with three-drug combination: Add spironolactone as fourth agent. 1 If spironolactone is ineffective or not tolerated, consider eplerenone, or add beta-blocker (if not already indicated), then centrally acting agent, alpha-blocker, hydralazine, or potassium-sparing diuretic. 1
Never combine two RAS blockers (ACE inhibitor with ARB) as this is contraindicated. 1
Multidisciplinary Care Coordination
Team-Based Approach
Ensure community-based multidisciplinary support including physiotherapists, occupational therapists, mental health social workers, psychiatrists, and community-based services for patients with social care needs. 1
Consider named care coordinators who can agree on courses of action with patients and carers, particularly important during transitions (e.g., moving to care home). 1
Utilize clinical pharmacists as integral members of the multidisciplinary team, as they have demonstrated improvements in medication adherence, diabetes parameters, blood pressure control, patient and provider satisfaction, reduced hospitalization, and cost savings. 1
Communication and Self-Management
Ensure ongoing adequate communication around medicines and wider care plans, identifying perceived benefits and ensuring patient involvement in the process. 1
Develop care plans that address ongoing medical and social care needs, focusing on enhancing social connectedness and community involvement while ensuring carers' needs are considered and that plans do not add to treatment burden. 1
Consider telehealth options and computerized decision support systems that support (but do not replace) clinical judgment. 1
Critical Safety Considerations
Drug Interactions and Special Populations
Patients with CKD require heightened vigilance: They are more susceptible to nephrotoxic medication effects, and impaired medication metabolism increases risk of adverse effects from prescribing errors leading to under- or over-dosing. 1
When prescribing antidepressants, muscle relaxants, nerve pain medications, and opioids: Each must be considered for side effects in the context of CKD and dosed appropriately due to increased adverse effects in this population. 1
For patients of childbearing potential with CKD: Always review teratogenicity potential and provide regular reproductive counseling. 1
In patients with extremes of body weight: Use eGFR non-indexed for body surface area, especially for medications with narrow therapeutic range or requiring minimum concentration for effectiveness. 1