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 higherthan-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 nonpharmacologic
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.
• 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.
• 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.
• 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.
• 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.
• 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.
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 inform