This advice is sourced from Dr Clifford Lisk and Dr Ros Taylor
Polypharmacy increases the risk of falls, delirium and drug interactions, all leading to hospital admission. It can also worsen frailty.
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.
Medications to consider stopping:
|
Class of medicine |
Examples |
Reasons to consider stoppping |
Cautions/notes |
|
All |
Any drug that the patient doesn't take, can't swallow or doesn't tolerate. |
Review indication |
|
|
Anti-anginals |
GTN, Isosorbide mononitrate |
If patient is asymptomatic - angina often reduced due to increased immobility Can cause hypotension |
Ensure patient still has access to GTN spray for acute symptoms. |
|
Anticoagulants and anti-platelets |
Aspirin, Clopidogrel, Warfarin, DOACs (eg Apixaban), LMW heparin injections |
Avoid anti-platelet agents if only for primary cardiovascular prevention. Stop anticoagulation where risk of bleeding outweighs the risk of clots (e.g 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. |
|
Anticholinergics |
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. |
|
Anti-arrhythmic drugs including beta-blockers |
Bisoprolol, Carvedilol |
Can cause hypotension Contribute to fatigue |
If symptomatic tachycardias are present, or if a betablocker is also helping angina, it may be advisable to continue treatment. |
|
Antihypertensives |
ACE Inhibitors and ARBs, Alpha blockers, Diuretics, Calcium channel blockers eg Amlodipine |
Blood pressure often 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 usually need to be continued. |
|
Dementia medications |
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. |
|
Cardiac glycosides |
Digoxin |
Impaired renal function can cause Digoxin toxicity (nausea, visual disturbance, arrhthmias) Can contribute to hypotension and fatigue |
Provides symptom relief in heart failure. Narrow therapeutic window; monitor renal function and electrolytes. Watch for signs of toxicity |
|
Osteoporosis treatments |
Bisphosphonates and Calcium supplements |
Unlikely to be of benefit in the short term. Weekly Alendronate can cause painful oesophageal ulceration |
|
|
Proton pump inhibitors and H2 receptor blockers |
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. |
|
Oral hypoglycaemics |
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 6-15 |
|
Lipid lowering treatments |
Statins, Ezetimibe, Bile acid sequestrants, Fibrates |
Unlikely to be of benefit in the short term |
|
|
Supplements |
Iron, Folate, Multivitamins |
Rarely relevant towards the end of life and add to the tablet burden. |
Top tips:
- 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