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Polypharmacy Stop Criteria

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the concurrent use of multiple medications by one individual is an increasingly common phenomenon that demands attention at clinical policy and practice level. Driven by the growth of an ageing population and the rising prevalence of multi-morbidity, polypharmacy has previously been considered something to avoid. It is now recognised as having both positive and negative potential, depending on how medicines and care are managed.

Issues

Overprescribing:Excessive doses/duration of medicines Polypharmacy
Misprescribing: Unfavourable choice of medicine, dose, or duration
Underprescribing: Not prescribing a clinically indicated medicine, despite the patient not having any contraindication to that medicine

Care taken when stopping

Particular caution should be taken if considering stopping the following drugs (continue treatment, gradual withdrawal or specialist advice before stopping):
ACEI and diuretics used in heart failure.
Amiodarone, calcium channel blockers, beta-blockers or Digoxin used to control heart rate or rhythm.
Anticonvulsants used in epilepsy.
Antidepressant, antipsychotic or mood-stabilizing drugs.
Antimuscarinic or other drugs used in Parkinson's disease.
Corticosteroids, DMARDs or immunosuppressant drugs

Table for Stop Medications

Digoxin	For heart failure with normal systolic ventricular function (no clear evidence of benefit) For left systolic ventricular dysfunction, where key interventions have not previously been tried (see START). A long-term dose greater than 125 micrograms/day if eGFR less than 30 ml/min/1.73m2 (risk of toxicity if Digoxin plasma levels not measured as eGFR may not be an accurate indicator of clearance).
Thiazide	Thiazide diuretic with current significant hypokalaemia (i.e. serum K⁺ less than 3.0 mmol/L), hyponatraemia (i.e. serum Na⁺ less than 130 mmol/L) hypercalcaemia (i.e. corrected serum calcium greater than 2.65 mmol/L) or with recent/ concurrent gout (hypokalaemia, hyponatraemia, hypercalcaemia and gout can be precipitated by thiazide diuretic).
Loop diuretic	Ad treatment for Hypertension (safer, more effective alternatives available). for dependent ankle oedema without clinical, biochemical evidence or radiological evidence of heart failure, liver failure, nephrotic syndrome or renal failure (leg elevation and/ or compression hosiery usually more appropriate).
Aldosterone antagonists (e.g. spironolactone, eplerenone)	AIIRAs particularly if co-prescribed with potassium-conserving drugs (e.g. ACEIs, amiloride, triamterene) without monitoring of serum potassium (risk of dangerous hyperkalaemia i.e. greater than 6.0 mmol/L - serum K should be monitored regularly, i.e. at least every 6 months).
Verapamil or diltiazem	With heart failure (may worsen heart failure).
Nicorandil	if ulceration of the gastro-intestinal tract, skin or mucosa (including eyes) occurs; consider alternative treatment or specialist advice if angina worsens (ulcers caused by Nicorandil do not respond to conventional treatment).
ACEIs or AIIRAs	Avoid in patients with hyperkalaemia. in combination with each other (limited evidence of benefit) - unless under specialist review and recommendation. Centrally-acting antihypertensives (e.g. methyldopa, clonidine, moxonidine), unless clear intolerance of, or lack of efficacy with, other classes of antihypertensives (centrally-active antihypertensives are generally less well tolerated by older people than younger people). Amiodarone as first-line antiarrhythmic therapy in supraventricular tachyarrhythmias (higher risk of side-effects than beta-blockers, Digoxin, verapamil or diltiazem), following review and recommendation by a specialist team. Non-selective beta-blocker with a recent history of bradycardia, heart block or uncontrolled heart failure; or asthma requiring treatment (risk of increased bronchospasm).
Aspirin:	Long-term Aspirin at doses greater than 150 mg per day (increased risk of bleeding, no evidence for increased efficacy).? with a past history of peptic ulcer disease without concomitant PPI (risk of recurrent peptic ulcer).? in combination with Warfarin or NOACs in patients with chronic atrial fibrillation? no added benefit from Aspirin). as monotherapy for stroke prevention in atrial fibrillation
Aspirin, Clopidogrel, dipyridamole, Warfarin or NOACs	with concurrent significant bleeding risk, i.e. uncontrolled severe hypertension, bleeding diathesis, recent non-trivial spontaneous bleeding (high risk of bleeding).
Aspirin plus Clopidogrel as secondary stroke prevention	unless the patient has a coronary stent(s) inserted in the previous 12 months or concurrent acute coronary syndrome or has a high grade symptomatic carotid arterial stenosis (no evidence of added benefit over Clopidogrel monotherapy).
Antiplatelet agents with Warfarin or NOACs	in patients with stable coronary, cerebrovascular or peripheral arterial disease (No added benefit from dual therapy).
Warfarin or NOACs	for first deep vein thrombosis without continuing provoking risk factors (e.g. thrombophilia) for longer than 6 months (no proven added benefit). for first pulmonary embolus without continuing provoking risk factors (e.g. thrombophilia) for longer than 12 months (no proven added benefit).
NSAID and Warfarin or NOACs in combination	(risk of major gastro-intestinal bleeding).
Direct thrombin inhibitors (e.g. dabigatran) if eGFR less than 30 ml/min/1.73m2	(risk of bleeding).
Factor Xa inhibitors (e.g. rivaroxaban, apixaban) if eGFR less than 15 ml/ min/1.73m2	(risk of bleeding).
Anti-muscarinic bronchodilators (e.g. ipratropium, tiotropium)	with a history of narrow angle glaucoma (may exacerbate glaucoma) or bladder outflow obstruction (may cause urinary retention).
Theophylline	as monotherapy for Asthma or COPD (safer, more effective alternatives; risk of adverse effects due to narrow therapeutic index).
Systemic corticosteroids	instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD (unnecessary exposure to long-term side-effects of systemic corticosteroids and effective inhaled therapies are available).

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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