As modern medicine has evolved through the ages, we are increasingly caught up in a career that is rife with guidelines and recommendations. Though well-meaning, many guidelines and recommendations are led by specialist groups and institutions that understandably focus only on a particular condition. It is then left to the astute clinician involved in the decision-making process of clinical management which is often followed by safe prescribing.

The commencement and continuation of medication on the basis of primum non nocere (‘first do no harm’) requires careful consideration on information at hand. Ideally, information that feeds into our clinical reasoning processes should involve core components of the clinical history, examination, investigation results, intended benefit and most importantly, patient preferences. In addition, I suggest reflecting on the available evidence and the patient’s time horizon.

Polypharmacy is a common outcome in today’s medicine; the use of multiple medications in our quest to help our patients. Polypharmacy can be deemed as appropriate or inappropriate. It is the responsibility of both, treating health professional(s) and patient, to help determine if intended benefits of treatment outweigh the risks and adverse effects. 

‘Polypharmacy is here’ in our everyday practice and the ageing population in the region will be more susceptible to inappropriate prescribing. A recently published Australian study found at least 1/3 of older Australians are subject to polypharmacy with figures rising to almost 1/2 in the oldest old1. Another recent article in GP Speak highlighted the benefits of deprescribing that led to both, patient and staff satisfaction, following sedative reduction in residential care2. With strategic reduction in sedatives such as benzodiazepines and antipsychotics, patients were more able to participate in activities of daily living and were more likely to have a better quality of life.

To help us reduce inappropriate prescribing and achieve appropriate polypharmacy (i.e. ‘safe prescribing’), the Scottish government have recommended ‘The 7-steps medication review’ that comprises the following3;

  • Step 1: (Aim) What matters to the patient?
  • Step 2: (Need) Identify essential drug therapy
  • Step 3: (Need) Does the patient take unnecessary drug therapy?
  • Step 4: (Effectiveness) Are therapeutic objectives being achieved?
  • Step 5: (Safety) Is the patient at risk of adverse drug reactions (ADRs) or suffers actual ADRs?
  • Step 6: (Efficiency) Is the drug therapy cost effective?
  • Step 7: (Patient-centred) Is the patient willing and able to take drug therapy as intended?

Other worthy steps that I suggest taking into consideration when prescribing include ensuring an ideal medication dose and remembering the basic sciences (e.g. pharmacology, physiology, pathophysiology) that may influence the likelihood of an intended benefit.

We are practicing medicine in exciting times. The pace that medical knowledge advances has provided us with a myriad of treatment options in various ailments while literally causing textbooks to be near obsolete! Thinking laterally beyond the hardcovers, I am also conscious that safe prescribing practice is especially important in an ever-increasing litigious environment that continues to take the hide off those in the pharmaceutical industry without always sparing the prescriber.

References:

  1. Polypharmacy among older Australians, 2006–2017: a population‐based study, Page et al. Med J Aust 2019; 211 (2): 71-75
  2. Sedative reduction improves resident care and staff satisfaction. Dr Breen J. 1st September 2019. GP Speak
  3. Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3rd Edition, 2018. Scottish Government