New advice on multiple prescribing and complementary medicines

The new recommendations from Choosing Wisely and the Pharmaceutical Society of Australia (PSA) are designed to help guide health professionals and patients by providing evidence-based advice about appropriate use of medicines.
 
There is certainly good reason to provide this advice, with around 230,000 Australians admitted to hospital each year due to medication misadventure – four times the number hospitalised because of motor vehicle accidents.
 
‘While the use of medicines offers significant benefits for many people, they may also cause unnecessary harm,’ PSA National President Dr Chris Freeman said.
 
‘It is important that we balance the positive and negative effects of each medicine, tailored to each individual with their care goals front of mind.’
 
In the context of primary care, 23% of adverse drug events are preventable, and the recommendations thus target aspects of prescribing that carry particular risk.
 
Pharmacists and primary healthcare professionals are warned against ‘prescribing cascade’, cautioned to avoid repeat prescriptions of antibiotics without review, and advised not to proffer homeopathic treatments due to a lack of evidence to support their effectiveness.
 

Dr Mark Morgan is pleased with the new recommendations, although he believes further clarification could be helpful.

Dr Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), said the RACGP is broadly supportive of the recommendations.
 
‘Overuse, misuse and abuse of these products has become a national health issue,’ he told newsGP. 
 
‘In particular, it is very pleasing to see that three of the six recommendations are focused on pharmacists’ involvement in homeopathic products, CAM [complementary and alternative medicine], and over-the-counter products.
 
‘The recommendation to check the appropriateness of repeat antibiotics script is also a welcome initiative, and will complement national AMS [antimicrobial stewardship] strategies to reduce inappropriate repeats of antibiotics.’
 
However, Dr Morgan also believes there are some areas that could benefit from further clarification.
 
‘While the issue of cascade prescribing is appropriate to address, it should not be confused with preventive prescribing, such as aperients with opioid medications or gastro-protection when prescribing anticoagulants where there is a history of peptic ulceration,’ he said.
 
‘These are very important situations to initiate therapy to treat or prevent adverse effects, and it may be wise for the PSA to clarify this.
 
‘It would also be appropriate for the PSA to publish guidance on the evidence for CAM therapies and over-the-counter products to support sales in community pharmacies.
 
‘I am also keen to emphasise that these recommendations speak to the professionalism of pharmacists and a willingness to prioritise patient care over product sales.’
 
Dr Morgan also noted that collaboration between pharmacists and prescribing doctors is important in upholding this advice, as is non-judgemental discussion with patients.
 
‘We want these Choosing Wisely recommendations to lead to better patient outcomes, rather than patients receiving conflicting advice,’ he said.
 
Choosing Wisely–Pharmaceutical Society of Australia recommendations

1. Do not initiate medications to treat symptoms, adverse events, or side effects (unless in an emergency) without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a medication, or another treatment is warranted.
2. Do not promote or provide homeopathic products as there is no reliable evidence of efficacy. Where patients choose to access homeopathic treatments, health professionals should discuss the lack of benefit with patients.
3. Do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness.
4. Do not prescribe medications for patients on five or more medications, or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements should or can be reduced or discontinued.
5. Do not continue benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium for more than three months without review.
6. Do not recommend complementary medicines or therapies unless there is credible evidence of efficacy and the benefit of use outweighs the risk.

Choosing Wisely Complementary medicines Homeopathy Pharmaceutical Society of Australia Primary care prescribing RACGP Expert Committee – Quality Care REC – QC recommendations