During a practice audit of patients over 75 years taking 10 or more regular medications, you identify several patients who would benefit from structured medication reviews. You are prioritising which patients to review first based on risk stratification. According to best practice guidance on medication reviews in primary care, which patient characteristic indicates HIGHEST priority for urgent structured medication review?

A patient recently discharged from hospital with five new medications added to their existing regimen

A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events

A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring

A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework

A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications

A 75-year-old man with COPD (post-bronchodilator FEV1 42% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes attends for medication review. He is on multiple inhalers: tiotropium, salmeterol/fluticasone 25/250 twice daily, and salbutamol as needed. Other medications include apixaban, bisoprolol, ramipril, atorvastatin, and metformin. He has had two exacerbations requiring oral steroids in the past year, the last one being 8 months ago. His current COPD symptoms are well-controlled with no exacerbations recently. Sputum cultures from his last exacerbation grew Pseudomonas aeruginosa. Which change to his inhaler therapy is MOST appropriate?

Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)

Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection

Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations

Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk

Add regular nebulised colistin for Pseudomonas suppression in COPD

You are conducting a structured medication review for an 80-year-old man with heart failure (NYHA class II), type 2 diabetes, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), and benign prostatic hyperplasia. He lives alone and manages his medications independently using a dosette box filled by his daughter. He takes 13 different medications at various times throughout the day. He mentions he sometimes forgets his evening doses and finds the regimen 'complicated'. Which approach BEST addresses medication adherence in this context according to principles of medicines optimisation?

Simplify the regimen by switching to once-daily preparations where possible and aligning administration times

Arrange for a district nurse to visit twice daily to supervise medication administration

Provide detailed written instructions about each medication and the importance of adherence

Reduce the total number of medications by stopping those not providing immediate symptom relief

Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia

A 70-year-old woman with rheumatoid arthritis, osteoporosis, hypertension, and gastro-oesophageal reflux disease attends for review. She takes: methotrexate 15mg weekly, folic acid 5mg weekly (taken day after methotrexate), prednisolone 5mg daily, alendronic acid 70mg weekly, omeprazole 20mg daily, amlodipine 10mg daily, and calcium/vitamin D daily. Blood tests show: Hb 102 g/L (MCV 88 fL), WCC 3.8 × 10⁹/L, platelets 156 × 10⁹/L, ALT 68 U/L (previously 32), eGFR 58 ml/min/1.73m². Which aspect of her medication regimen requires MOST urgent attention?

The elevated ALT indicating methotrexate hepatotoxicity requiring dose reduction or cessation

The alendronic acid and omeprazole combination reducing bisphosphonate absorption

The low haemoglobin suggesting methotrexate-induced bone marrow suppression requiring urgent cessation

The combination of prednisolone and alendronic acid requiring additional osteoporosis monitoring

The declining renal function requiring methotrexate dose adjustment or alternative DMARD

A practice pharmacist is conducting a quality improvement project on anticholinergic burden in elderly patients with multimorbidity. She identifies a 73-year-old man taking 12 medications with a total Anticholinergic Cognitive Burden (ACB) score of 6. His medications include amitriptyline 50mg nocte for neuropathic pain, tolterodine 4mg for overactive bladder, lansoprazole 30mg, co-codamol 30/500, atorvastatin, ramipril, bisoprolol, aspirin, and metformin. He reports feeling 'foggy-headed' and has had two falls. Which intervention would have the GREATEST impact on reducing anticholinergic burden?

Address both amitriptyline and tolterodine simultaneously by switching to alternatives

Switch tolterodine to mirabegron, a beta-3 agonist with no anticholinergic activity

Replace amitriptyline with duloxetine for neuropathic pain management

Stop lansoprazole as proton pump inhibitors contribute to cognitive impairment

Reduce co-codamol dose as opioids can contribute to cognitive impairment

A 76-year-old woman with dementia (MMSE 18/30), Parkinson's disease, type 2 diabetes, and recurrent falls is brought by her daughter for medication review. Current medications include: co-careldopa 25/100 three times daily, ropinirole 8mg three times daily, quetiapine 25mg twice daily, metformin 500mg twice daily, gliclazide 40mg twice daily, alendronic acid 70mg weekly, calcium/vitamin D, and PRN paracetamol. She has had three falls in the past two months. Her daughter reports increasing confusion and hallucinations. Blood glucose monitoring shows values between 4.8-8.2 mmol/L. Which medication intervention should be prioritised?

Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first

Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls

Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms

Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls

Stop alendronic acid as bisphosphonates increase fall risk in elderly patients

A 68-year-old man with ischaemic heart disease, permanent atrial fibrillation, type 2 diabetes, and osteoarthritis takes: aspirin 75mg, apixaban 5mg twice daily, bisoprolol 5mg, atorvastatin 80mg, metformin 1g twice daily, gliclazide 80mg twice daily, and paracetamol as required. He has no history of stenting or acute coronary syndrome in the past 12 months. His most recent echocardiogram shows LVEF 55% with no wall motion abnormalities. His CHA₂DS₂-VASc score is 5. Which medication change is MOST appropriate?

Stop aspirin as dual antiplatelet and anticoagulation increases bleeding risk without additional benefit

Stop apixaban and continue aspirin alone for cardiovascular protection

Continue both medications as dual therapy is indicated in atrial fibrillation with ischaemic heart disease

Stop both aspirin and apixaban and commence warfarin for better control

Reduce apixaban to 2.5mg twice daily when used in combination with aspirin

During a structured medication review using the STOPP/START criteria for a 71-year-old woman, you identify she takes co-codamol 30/500 four times daily for chronic lower back pain, alongside atorvastatin, ramipril, and bisoprolol. She mentions she has been constipated for several weeks and also takes senna tablets daily. She has no history of major surgery or inflammatory spinal disease, and her back pain has been present for 18 months. Her renal function and liver function are normal. Which action represents BEST practice according to deprescribing principles?

Gradually reduce and stop codeine while optimising non-opioid analgesia and addressing pain holistically

Switch co-codamol to tramadol to reduce constipation while maintaining analgesia

Add a stimulant laxative such as sodium picosulfate to manage opioid-induced constipation

Continue current regimen but refer for specialist pain management assessment

Switch to modified-release morphine for more consistent pain control

A 74-year-old man attends for medication review. He has heart failure (LVEF 32%), atrial fibrillation, type 2 diabetes, stage 3b CKD (eGFR 36 ml/min/1.73m²), and benign prostatic hyperplasia. Current medications: bisoprolol 10mg, ramipril 10mg, furosemide 40mg, spironolactone 25mg, apixaban 5mg twice daily, metformin 1g twice daily, empagliflozin 10mg, finasteride 5mg, tamsulosin 400mcg, atorvastatin 80mg. Blood tests show potassium 5.4 mmol/L, sodium 134 mmol/L, urea 12.8 mmol/L, creatinine 168 μmol/L (stable). He reports good symptom control but occasional dizziness on standing. Which represents the BEST management approach?

Continue current regimen with close monitoring as benefits outweigh risks

Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications

Reduce ramipril to 5mg daily to decrease potassium and improve renal function

Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment

Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy

According to the Beers Criteria for potentially inappropriate medication use in older adults, which of the following medications should be avoided in elderly patients regardless of diagnosis or condition?

Long-acting benzodiazepines such as diazepam and chlordiazepoxide

Non-selective beta-blockers in patients with peripheral vascular disease

First-generation antihistamines in patients with cognitive impairment

Proton pump inhibitors when used for longer than 8 weeks

Thiazide diuretics in patients with a history of gout

Polypharmacy - Free UK Medical PG Review

Quick Overview

Polypharmacy (≥5 regular medications) affects 10-20% of UK adults, rising to >50% in those aged >65 years. Problematic polypharmacy occurs when medications cause harm through drug interactions, adverse effects, or prescribing cascades. NICE NG56 emphasizes structured medication review to optimize appropriate polypharmacy while minimizing harm, particularly in frail elderly patients.

Core Facts & Concepts

Definitions & Thresholds

Polypharmacy: ≥5 regular medications
Hyper-polypharmacy: ≥10 regular medications
Problematic polypharmacy: Medication use causing harm outweighing benefit
Appropriate polypharmacy: Evidence-based prescribing for multiple conditions

Anticholinergic Burden Scale (ACB)

Score 1 (mild): Codeine, furosemide, ranitidine
Score 2 (moderate): Carbamazepine, loperamide
Score 3 (severe): Amitriptyline, oxybutynin, hyoscine
Total ACB ≥3: Associated with 50% increased risk of falls, cognitive impairment, mortality

![Anticholinergic Burden Scale showing scoring system with medication examples and associated risks](Image: anticholinergic burden scale)

High-Risk Medications in Elderly (STOPP/START Criteria)

NSAIDs: Increase bleeding risk 4-fold with anticoagulants
Benzodiazepines: Falls risk increased 1.5-fold
Tricyclic antidepressants: ACB score 3, cardiac conduction effects
Antipsychotics: Stroke risk doubled in dementia patients
PPIs: Long-term use (>8 weeks) without indication-C. difficile risk

Prescribing Cascades

Metoclopramide → parkinsonism → levodopa prescribed
Thiazide diuretic → gout → NSAIDs prescribed
NSAID → hypertension → additional antihypertensive added
Cholinesterase inhibitor → urinary incontinence → anticholinergic prescribed

Problem-Solving Approach

Structured Medication Review (NICE NG56)

Identify all medications (including OTC, herbal)
Assess indication for each drug-still valid?
Check for drug-drug and drug-disease interactions
Calculate anticholinergic burden (target ACB <3)
Review adherence and patient understanding
Optimize doses for renal/hepatic function
Deprescribe where harm exceeds benefit
Monitor for 4-8 weeks post-changes

Red Flags 🚩

New confusion/falls in patient on ≥5 medications
ACB score ≥3 with cognitive symptoms
eGFR <30 ml/min without dose adjustments
Triple whammy: NSAID + ACEi + diuretic
Duplicate therapy (e.g., 2 benzodiazepines)

Deprescribing Priorities

Medications without clear indication
Drugs treating side effects of other drugs
Medications with ACB score ≥2
Drugs exceeding treatment duration (e.g., PPIs >8 weeks)
Medications with narrow therapeutic index in frail patients

⚠️ Warning: Never stop medications abruptly-taper benzodiazepines, beta-blockers, SSRIs, corticosteroids over weeks

Analysis Framework

Medication Review Decision Tool

Assessment Domain	Action Required If	Intervention
Indication	No current evidence-based indication	Deprescribe with patient agreement
Effectiveness	Not achieving therapeutic goal	Optimize dose or switch agent
Safety	ACB ≥3 or high-risk combination	Substitute lower-risk alternative
Adherence	Missing >20% of doses	Simplify regimen, use compliance aids
Patient preference	Unwilling to continue	Shared decision to stop/reduce

Drug Interaction Risk Stratification

High risk: Warfarin + NSAID, SSRI + NSAID (bleeding)
Moderate risk: ACEi + spironolactone (hyperkalaemia)
Pharmacodynamic: Beta-blocker + verapamil (bradycardia)
Pharmacokinetic: Clarithromycin + simvastatin (rhabdomyolysis)

Visual Aid

Deprescribing Taper Guide

Drug Class	Taper Duration	Monitoring
Benzodiazepines	4-12 weeks (reduce 10-25% every 1-2 weeks)	Anxiety, insomnia, seizures
Beta-blockers	1-2 weeks	HR, BP, angina symptoms
PPIs	Switch to H2RA for 2 weeks then stop	Rebound dyspepsia
SSRIs	2-4 weeks	Discontinuation syndrome
Corticosteroids	Variable (>3 weeks use)	Adrenal insufficiency

Key Points Summary

✓ Polypharmacy ≥5 drugs; problematic when harm exceeds benefit-affects >50% of patients >65 years

✓ Anticholinergic Burden (ACB) ≥3 increases falls risk 1.5-fold, cognitive impairment, and mortality by 50%

✓ STOPP/START criteria identify inappropriate prescribing-NSAIDs, benzodiazepines, TCAs highest risk in elderly

✓ Prescribing cascades occur when side effects are treated with additional drugs (e.g., metoclopramide → parkinsonism → levodopa)

✓ Structured medication review (NICE NG56): Assess indication, effectiveness, safety, adherence-deprescribe where appropriate

✓ Never stop abruptly: Taper benzodiazepines (4-12 weeks), beta-blockers (1-2 weeks), SSRIs (2-4 weeks), corticosteroids

✓ Triple whammy (NSAID + ACEi + diuretic) causes AKI-avoid in elderly and monitor renal function closely

Polypharmacy

Polypharmacy

On this page

Quick Overview

Core Facts & Concepts

Problem-Solving Approach

Analysis Framework

Visual Aid

Key Points Summary

Practice Questions: Polypharmacy

Flashcards: Polypharmacy

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