17th May 2025

Medicine reconciliation

Polypharmacy is the concurrent use of 4 or more regular medications in an individual. It can be appropriate in many instances in patients with complex comorbidities, but clinicians must be able to recognise inappropriate polypharmacy that is much more common in older people.

Problems & consequences of inappropriate polypharmacy include:

• Adverse drug interactions
• Pill burden
  • Poor compliance
  • Confusion as to what, when and how to take drugs
  • Sense of lack of control over own healthcare
• Increased hospital admission and healthcare cost

Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) are evidence-based guidelines used in the United Kingdom aimed to prevent inappropriate prescribing and omission of essential medicines (seeTable 3). Utilising STOPP/START criteria has reduced the number of adverse drug events and medical costs, whilst improving activities of daily living.

Table 3. Summary of STOPP guidance

As a general principle, any duplication of drug class should be reviewed and preferably removed to reduce side effects and polypharmacy. Avoid concurrent use of several sedative medications due to increased risk of overdose and respiratory depression.

Despite general clinical consensus regarding stopping anticoagulants in recurrent falls, there has not been any evidence supporting this. Starting or stopping anticoagulants for specific indications (e.g., atrial fibrillation) should be based on a balance of risks between risk of thrombotic event and bleeding risks. Scoring systems should be utilised to make an informed decision (i.e. CHA2DS2-VASc score for risk of cerebrovascular event in atrial fibrillation, ORBIT and HASBLED for risk of bleeding).

Table 4. Summary of START guidance

Warfarin is an important medication to take note of when starting or stopping medications as many drugs can affect its anticoagulant effect, mainly by potentiating or inhibiting the cytochrome P450 system responsible for metabolising warfarin. When starting any drugs that can alter warfarin metabolism (Table 5), monitor international normalised ratio (INR) closely and modify warfarin dose if necessary. Several antibiotic classes and antiepileptic drugs (AED) are the most common causes. Patients will also need to be reminded that some food items should be avoided to maintain a stable Warfarin level. Patients with liver disease are likely to have impaired Warfarin metabolism, thus a lower dose may be required to achieve target INR.

Table 5. Drugs that alter warfarin anticoagulant effect

Below is a simple guide as to how to reconcile and review medications for elderly patients:

• Remove medications that are not indicated by their current conditions
• Limit the range of drug class to reduce possible drug-drug interactions
• Start with lower dosage within the effective range, and titrate according to symptoms slowly if necessary
• Simplify regimen and keep the number of doses per day to a minimum
• Review regularly, especially at each admission and change in condition