Think carefully before prescribing medicines

Think carefully before prescribing medicines – Council of Medical Colleges

The Council of Medical Colleges is encouraging clinicians to think carefully about the medications they prescribe for patients.

Chair Dr Derek Sherwood says it is important clinicians consider how the medicines they prescribe interact with one another, whether they are really necessary, and whether they could potentially harm their patient.

“As part of the Choosing Wisely campaign we have worked with Australasian and New Zealand Colleges and specialist societies to develop specific recommendations about medication use. These recommendations include considering non-pharmacological treatments rather than prescribing medication; being aware of the ‘prescribing cascade’ and the potential harms of polypharmacy; and not prescribing a higher-than-needed dose.”

The medication use recommendations are:

• Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others.

• Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium. There is strong evidence that use of benzodiazepines is associated with various adverse effects in elderly people such as falls and fractures. For more information seehttp://choosingwisely.org.nz/professional-resource/anzsgm/#2

• Do not prescribe medication without conducting a drug regimen review. Older patients disproportionately use more prescription and non-prescription drugs than other populations and such polypharmacy increases the risk of adverse drug reactions and hospital admissions. For more information seehttp://choosingwisely.org.nz/professional-resource/anzspm/#5

• Recognise and stop the ‘prescribing cascade’ which can occur when a new medicine is prescribed to ‘treat’ an adverse reaction to another drug in the mistaken belief that a new medical condition requiring treatment has developed. For more information see http://choosingwisely.org.nz/professional-resource/ascept/#1

• Reduce the use of medicines when there is a safer or more effective non-pharmacological management strategy. Pharmacological treatments may detract from behaviour management tools that have proven effective in managing these same problems. For more information see http://choosingwisely.org.nz/professional-resource/ascept/#2

• Avoid using a higher or lower dose than is necessary for the patient to optimise the ‘benefit-to-risk’ ratio and achieve the patient’s therapeutic goals. As patients become more frail, potential harms usually increase and potential benefits usually decrease for a given dosage of pharmacological treatment. Also note that high drug doses are not necessarily more effective than low doses.

• Stop medicines when no further benefit will be achieved or the potential harms outweigh the potential benefits for the individual patient. This is particularly pertinent for elderly patients with a limited life expectancy where the treatments are unlikely to prevent disease, and may lead to adverse effects that reduce quality of life. For more information see http://choosingwisely.org.nz/professional-resource/ascept/#3

• Reduce the use of multiple concurrent therapeutics (hyper-polypharmacy). Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes; hospital admissions; and, deaths. For more information see http://choosingwisely.org.nz/professional-resource/ascept/#5

Dr Sherwood says each recommendation is based on the best available evidence.

“The recommendations are not prescriptive but are intended as guidance to start a conversation about what is appropriate and necessary.

“As each situation is unique, health care professionals and patients should use the recommendations to develop together an appropriate health care plan.”

The Choosing Wisely campaign is being run by the Council of Medical Colleges, in partnership with the Health Quality & Safety Commission and Consumer. A number of other medical organisations are supporting the campaign. The campaign emphasises that not all medications, tests, treatments and procedures bring benefits and encourages people to ask questions about their health care. For more information see: http://choosingwisely.org.nz/

This week is Patient Safety Week, coordinated by the Health Quality & Safety Commission. The focus of the week is medication safety – in particular encouraging people to ask questions about their medicines. For more information see: https://www.hqsc.govt.nz/our-programmes/patient-safety-week/

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