Polypharmacy increases the risk of drug interactions, hospital admission and can worsen frailty, falls and delirium.
Medicines are prescribed for 3 reasons:
- prevention of future harm
- control of illness
- symptomatic relief
Consider the original reason for each medication - then review whether it still has any symptomatic benefit -or whether it may now be causing harm.
Preventative medications to consider stopping:
|Class of medicine
|Reasons to consider stoppping
|Any drug that the patient doesn't take or doesn't tolerate.
|Anticoagulants and anti-platelets
|Aspirin, clopidogrel, warfarin, DOACs
Avoid anti-platelet agents for primary cardiovascular prevention.
Stop anticoagulation where the risk of bleeding outweighs the risk of clots (for example in the case of a GI tumour)
Stopping anticoagulation/assessing bleeding risk is often a difficult decision which is best made with colleagues.
Consider using HAS-BLED to assess risk.
|Oxybutinin, Buscopan, Chlorphenamine, Amitriptyline
|Side effects include falls, dry mouth, constipation and confusion.
|Note the overall anticholinergic burden and whether some drugs can be omitted safely.
|ACE Inhibitors and ARBs, Alpha blockers, Diuretics, Calcium channel blockers
Often blood pressure reduces with advancing illness, and hypotension causes fatigue and falls.
Stop ACEi/ARBs that are used solely for renal protection (e.g in diabetes).
|Diuretics in heart failure often need to be continued.
|Antipsychotics, Aricept, Memantine
Consider reducing doses of antipsychotics if level of distress is low.
Memantine and Aricept are no longer of benefit in advanced disease and may cause falls and insomnia.
|All dementia medications should be tapered rather than stopped suddenly.
|Bisphosphonates and calcium supplements
Unlikely to be of any benefit in the short term.
Weekly alendronate can cause oesophageal ulceration.
|Proton pump inhibitors and H2 receptor antagonists
|Lansoprazole, Omeprazole, Famotidine
|Should not be required at full therapeutic dose without a current indication (e.g for symptoms or gastroprotection)
|May be required if on steroids or NSAIDs.
|Metformin, sulphonylureas, gliptins, glitazones
Prevention of future diabetic complications is no longer relevant.
Aim for monotherapy if any therapy is needed.
|Aim for blood sugars 5-17
|Lipid lowering treatments
|Statins, ezetimibe, bile acid sequestrants, fibrates
|Need to be prescribed for a long duration to be of benefit.
|Iron, Folate, Multivitamins
|Rarely relevant towards the end of life and add to the tablet burden.
- Review inhaler technique - these are often not properly used in advancing illness and can be stopped
- Useful phrase "Some of your medicines that used to help you may no longer be of benefit''
- Focus on the benefits of stopping rather than the futility of continuing
- Always ask about 'over the counter' and herbal medicines