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Clinical practice guidelines for older people with multi-morbidity and life limiting illness: what are the implications for deprescribing?

Lookup NU author(s): Dr Adam Todd

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This is the authors' accepted manuscript of an article that has been published in its final definitive form by Sage Publications Ltd., 2018.

For re-use rights please refer to the publisher's terms and conditions.


Abstract

Objectives:To apply current NICE clinical practice guidelines to a hypothetical older patient with multi-morbidity and life limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. Methods:Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment resistant model, and a last line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). Results:The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication – with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment resistant model, 6 separate medications (15 dosage units); and, for the last line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. Conclusions:In a UK context, disease specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life limiting illness and multi-morbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when the medications should be reduced or stopped.


Publication metadata

Author(s): Okeowo D, Patterson A, Boyd C, Reeve E, Gnjidic D, Todd A

Publication type: Article

Publication status: Published

Journal: Therapeutic Advances in Drug Safety

Year: 2018

Volume: 9

Issue: 11

Pages: 619-630

Print publication date: 01/11/2018

Online publication date: 12/09/2018

Acceptance date: 02/07/2018

ISSN (print): 2042-0986

ISSN (electronic): 2042-0994

Publisher: Sage Publications Ltd.

URL: https://doi.org/10.1177/2042098618795770

DOI: 10.1177/2042098618795770


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