Megan Fawkes is a hospital pharmacist currently undertaking a Polypharmacy Project secondment at Wirral University Teaching Hospital NHS Foundation Trust.
Problematic polypharmacy can be defined as the inappropriate prescribing of multiple medications for an individual where the risks of taking the multiple medications outweigh the benefits, or the intended benefits of taking the medications are not realised. Problematic polypharmacy increases the risk of many adverse health outcomes including adverse drug reactions, falls and hospital admissions, and is a significant and escalating public health problem.
Problematic polypharmacy has traditionally been addressed by deprescribing as part of structured medication reviews completed in primary care. However, as many patients who are experiencing polypharmacy are admitted to hospital each day, and some may have a longer inpatient stay whilst awaiting discharge planning, is this a missed opportunity for hospital pharmacists to do more to address problematic polypharmacy?
To assess this, as part of the Cheshire and Merseyside ICB system-wide polypharmacy transformation programme, Wirral University Teaching Hospital NHS Foundation Trust (WUTH) successfully bid for funding to employ a fixed term highly specialist hospital pharmacist, starting in October 2025, to focus on reducing inappropriate polypharmacy within the inpatient setting but also supporting other settings across our system.
Additional services that have been designed and implemented as part of the role to realise this change include:
- Enhanced inpatient falls focused medication reviews for targeted inpatient cohorts and patients referred by other colleagues.
- Proactive falls medication reviews for patients at risk of falls in the community, in collaboration with a community falls prevention service.
- Polypharmacy Advice and Guidance sessions to support primary care clinicians with complex deprescribing decisions with support from specialists in different clinical areas e.g. insomnia, falls.
Endpoints that were measured to demonstrate success of medication reviews included a reduction in the total number of medications prescribed, total anticholinergic burden (ACB) score and total number of falls risk increasing drugs (FRIDs) prescribed, as well as reduction in doses of medications with an ACB score and FRIDs.
As a result of enhanced medication reviews, a significant number of medications which had been continued on admission to hospital were able to be deprescribed and subsequently not continued on discharge. Some of the memorable deprescribing interventions include:
- Chlorphenamine that was started 2 years ago regular at night for itching.
- Quetiapine for a patient who had Parkinson's Disease in collaboration with the inpatient psychiatry team.
- Amitriptyline that the patient had been taking for 5 years and did not know what the indication was.
- Solifenacin in a patient with a long-term catheter that was started 4 years ago following a urological procedure prior to having a catheter.
Similar success stories have been realised in proactive falls medication reviews for patients in the community, including stopping diphenhydramine that the patient was buying online and taking above licensed doses; she was unaware that this medication was potentially contributing to her dizziness and falls and admitted that she was so fearful of falling that she rarely left the house.
Addressing problematic polypharmacy in a secondary care setting has not been without challenges. Barriers to address problematic polypharmacy in secondary care include, but are not limited to:
- Difficulty identifying patients experiencing problematic polypharmacy - Hospital electronic prescribing systems typically highlight patients for medication review by factors such as the number of non-verified medications, rather than polypharmacy indicators e.g. the total number of medications prescribed.
- Different priorities in secondary care - key performance indicator (KPI) targets prioritise medicines reconciliation on admission for example, meaning that deprescribing is often deprioritised in routine clinical practice.
To overcome these barriers, key enablers that contributed to the success of the role include:
- Integration within multidisciplinary teams (MDTs) – to increase engagement of other clinicians and provide further opportunity for medication optimisation.
- Workforce development and cultural change – education activities were delivered to junior doctors, pharmacists and wider pharmacy teams to raise awareness of the importance of addressing problematic polypharmacy and embed deprescribing principles into routine practice.
- Establishing seamless referral processes - to increase engagement and collaboration with other clinicians, teams and services and enable proactive identification of the most at-risk patients.
This role highlights the opportunity that hospital pharmacists have on a daily basis to deprescribe inappropriate medications. Key take home messages for hospital pharmacists are:
- Every contact with the patient counts - what can we do whilst they are an inpatient to optimise their care and reduce the risk of readmission?
- To have a productive conversation with a patient about deprescribing, you need to invest the time to listen to them and find out what’s most important to them- it might not be what you think!
- Be curious and find out what the indications are for pre-admission medications and when they were started.
- Communicate all medication changes and recommendations for follow up/further deprescribing in patients’ discharge letters.
