Polypharmacy Guidance: appropriate prescribing, making medicines safe, effective and sustainable 2025 - 2028

Gastrointestinal (GI) bleeding, concomitant use of NSAIDs and SSRIs

This considers the impact of prescribing a non-steroidal anti-inflammatory drug (NSAID) and a selective serotonin re-uptake inhibitor (SSRI) at the same time and the increased risk of GI bleeding if these are taken together.

• Where possible, the NSAID should be stopped. If an NSAID is essential, then the shortest possible course should be used.
• GI protection with a proton pump inhibitor (PPI) may need to be considered, especially in older adults, who are at greater risk of SSRI-associated bleeding, or those with a history of GI bleed.
• Antidepressants should be regularly reviewed
• Encourage non-pharmacological approaches for depression/anxiety and physical activity for both depression and joint pain

Use of combination blood thinners

Blood thinning treatment is widely used as an effective therapy to lower the risk of a range of events.

• Indication and duration should be clear both at commencing treatment and with continuing use

• Managing bleeding risk:
  • Ensure that bleeding risk is not increased by co-prescription of agents that increase risk of bleeding
  • Consider use of gastroprotection
• If a blood thinning agent is no longer indicated or safe, it should be stopped.
• If gastroprotection was started to reduce the risk of bleeding with a blood thinner and that blood thinner is then stopped, consider stopping gastroprotection.

Acute Kidney Injury

This considers the impact of the triple whammy where any three of metformin, an ACEI (angiotensin-converting enzyme inhibitor), ARB (angiotensin II receptor blocker), NSAID (non-steroidal anti-inflammatory drug) and a diuretic are prescribed.

• Where possible, NSAIDs should be stopped. If an NSAID is essential, then the shortest possible course should be used, and renal function reassessed regularly.
• Discuss Medication Sick Day Guidance

Concomitant use of any three of opioids, benzodiazepines, z-drugs, gabapentinoids or antidepressants

This hot topic considers the impact of concurrent prescribing of any three of: opioids; benzodiazepines; z-drugs; gabapentinoids or antidepressants. This increases sedation, falls, severe respiratory depression, the potential for dependency and possible withdrawal reactions when these medicines are stopped.

• The risk of harm increases with the number of these medicines taken concurrently. There should be assessment of risk factors such as history of problem substance/alcohol use.
• Pharmacological and non-pharmacological approaches should be considered as treatment options and reviewed regularly for effectiveness.
• Where possible, when used for non-essential use, these medicines should be stopped
• Reduction of therapy should be controlled, not sudden, to manage the risk of withdrawal symptoms
• Only co-prescribe benzodiazepines with opioids if there is no alternative and, if necessary, the lowest possible doses should be given for the shortest duration
• Monitor individuals closely for signs of respiratory depression at initiation of treatment and when there is any change in prescribing, such as dose adjustments of new interactions

Medication Sick Day Guidance

The aim of the Medication Sick Day Guidance is to prevent such adverse events by temporarily withholding medication during episodes of acute dehydrating illness and restarting once the individual is well.

• Medication Sick Day Guidance may be appropriate for those taking one of more of the following medicines:
  • Sulfonylureas or sodium-glucose co-transporter-2 (SGLT-2) inhibitors
  • Angiotensin-converting enzyme (ACE_ inhibitors)
  • Diuretics
  • Metformin
  • Angiotensin receptor blockers (ARB)
  • Non-steroidal anti-inflammatory drugs (NSAID)

• A person-centred approach should be used with the Medication Sick Day Guidance. Prior to provision, consider the individual’s risks and benefits of following the Medication Sick Day Guidance, as the guidance may not be suitable for some individuals