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Drug Policy is based on a fine balance between future benefit and harm. However, over-prescription is a growing problem: 6.5% of all hospital admissions are caused by adverse drug reactions (1), leading to increasing costs to both the patient and the healthcare system. In particular, there is a growing problem with over-prescription of antibiotics in primary care, where infections are mostly viral. This has contributed to the emergence of antibiotic resistant strains of bacteria, which has become a significant threat to patient safety.

Another example of controversy regarding over-prescription is with statins – the UK’s most commonly prescribed drugs (2).While undisputed evidence shows that they are effective in people at high risk of stroke and heart disease, for people with low risk of these conditions (3) it is unclear and whether the benefits outweigh the potential side effects (4) . This is because recommendations were made on the basis of data from clinical trials that data only assessed limited adverse effects, which were poorly characterised.

Polypharmacy

Polypharmacy is the concurrent use of multiple medications in a patient. It is largely driven by the increasing prevalence of multi-morbidity (several conditions) within the ageing population. Diabetes mellitus, hypertension, heart disease, arthritis and cancer are common in this demographic and require many medications for proper treatment. Treatments employing multiple medications can improve outcomes for patients, improve their quality of life and extend life expectancy.

As with all clinical interventions, in order to determine therapeutic efficacy or predict prognosis clinical trials are necessary; however, for medically complex older individuals this evidence base is very poor. Despite multi-morbidity being a global and widespread problem, health care systems and practice guidelines still tend to use a single-disease framework.

Polypharmacy and potentially inappropriate medication (PIM) use are thorny issues in geriatric medicine with significant clinical, economic and humanistic impacts. Problematic polypharmacy occurs when the intended benefit of medication is not realised, or multiple medications are prescribed inappropriately or unnecessarily. This may happen if a prescriber inadvertently prescribes new medication to counteract symptoms that are actually side effects caused by other medications.

Polypharmacy can increase the risk of drug interactions undermining the therapeutic benefits and the incidence of adverse drug reactions, which worsen the patient’s quality of life. A recent study on a hospitalised geriatric patient group showed that over half were prescribed PIMs (5). When medicating older patients, adverse drug reactions may occur for various reasons including: interactions with drug-drug and drug-food, improper medication administration, decreased rate of metabolism and poor patient compliance (6).Furthermore, research has shown excessive polypharmacy (6-9 drugs) as a mortality indicator in elderly populations (7).

Healthcare is a limited resource thus the appropriateness of drug use should be reviewed regularly to avoid wastage of public money. Drug expenditures are typically skewed, with the top 3% of patients prescribed excessive polypharmacy accounting for 22% of the total pharmaceutical expenditures (8). Aside from potential drug reactions and side effects, over-prescribing PIMs will occur at cost of being unable to pay for other much needed medical services.

Recognising PIM

Recognising PIM in older adults is critical, and this can achieved using explicit identification criteria, the most commonly used are the updated Beers criteria 2012 (9) and the STOPP screening tool (10).These sets of criteria vary in their ability to identify PIM use in specific settings (11-13) and they work best when used in a complementary manner (9, 10).Studies showed that these criteria not only identified a high prevalence of PIM use, but also that its use was associated with adverse drug reactions as well as functional decline (14).

Although the overall of PIM usage is estimated to be high, according to the studies carried out in the USA and Sweden there has been a decline observed in recently (15, 16). However, findings from intervention trials suggests that while the employment of such criteria reduces the level of polypharmacy and PIM use as well as drug interactions, improvement in patient outcomes such as mortality and morbidity as not been observed (17) so further refinements are clearly required.

Reviewing prescriptions regularly is important for optimal patient care, particularly as patients get older, receive more medicines, or develop more illnesses. Recently, a set of guidelines was formulated by The King’s Fund in order to promote awareness and training in medicines management, multi-morbidity and optimal polypharmacy across all levels of healthcare, whilst minimising harm and waste (18) (Box 1) .

Box 1: King’s Fund Report – key findings and recommendations (précis) (18)

Key findings

  • appropriate polypharmacy will extend life expectancy and improve quality of life in some patients
    polypharmacy can… increase risk of drug interactions and adverse drug reactions, impair adherence to medication, and affect quality of life for patients
  • …it is important that pragmatic clinical trials are conducted that include patients with multi-morbidity and polypharmacy
  • during medication reviews, prescribers should consider if treatment should be stopped and ‘end-of-life’ care be offered for certain chronic conditions or cancer-related illness
  • patients with multi-morbidity could have all their long-term conditions reviewed in one visit by a clinical team responsible for co-ordinating their care
  • patients may struggle with complex drug regimens; their perspective on medicine-taking must be taken into account when prescribing.

 

Conclusion

The NHS must stay abreast of increasingly complex medical circumstances; for this a holistic approach to is needed. Furthermore, this individualised approach to healthcare should be welcomed and not viewed as a deviation from ‘best practice’ on the basis of treatment guidelines for individual diseases.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ. 2004;329(7456):15-9. Epub 2004/07/03.
  2. British Heart Foundation. Statins. Available from: http://www.bhf.org.uk/heart-health/treatments/statins.
  3. National Institute for Health and Care Excellence. NICE clinical guideline 181. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. . 2015.
  4. Ferket BS, van Kempen BJ, Heeringa J, Spronk S, Fleischmann KE, Nijhuis RL, et al. Personalized prediction of lifetime benefits with statin therapy for asymptomatic individuals: a modeling study. PLoS medicine. 2012;9(12):e1001361. Epub 2013/01/10.
  5. Danisha P, Dilip C, Mohan PL, Shinu C, Parambil JC, Sajid M. Identification and evaluation of potentially inappropriate medications (PIMs) in hospitalized geriatric patients using Beers criteria. Journal of basic and clinical physiology and pharmacology. 2015;26(4):403-10. Epub 2015/05/08.
  6. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. The American journal of geriatric pharmacotherapy. 2007;5(4):345-51. Epub 2008/01/09.
  7. Jyrkka J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs & aging. 2009;26(12):1039-48. Epub 2009/11/26.
  8. Saastamoinen LK, Verho J. Register-based indicators for potentially inappropriate medication in high-cost patients with excessive polypharmacy. Pharmacoepidemiology and drug safety. 2015;24(6):610-8. Epub 2015/03/03.
  9. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2012;60(4):616-31. Epub 2012/03/02.
  10. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age and ageing. 2008;37(6):673-9. Epub 2008/10/03.
  11. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. Journal of clinical pharmacy and therapeutics. 2013;38(5):360-72. Epub 2013/04/05.
  12. Hudhra K, Garcia-Caballos M, Jucja B, Casado-Fernandez E, Espigares-Rodriguez E, Bueno-Cavanillas A. Frequency of potentially inappropriate prescriptions in older people at discharge according to Beers and STOPP criteria. International journal of clinical pharmacy. 2014;36(3):596-603. Epub 2014/04/20.
  13. Curtain CM, Bindoff IK, Westbury JL, Peterson GM. A comparison of prescribing criteria when applied to older community-based patients. Drugs & aging. 2013;30(11):935-43. Epub 2013/09/05.
  14. Stel VS, Smit JH, Pluijm SM, Lips P. Consequences of falling in older men and women and risk factors for health service use and functional decline. Age and ageing. 2004;33(1):58-65. Epub 2003/12/30.
  15. Davidoff AJ, Miller GE, Sarpong EM, Yang E, Brandt N, Fick DM. Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers criteria. Journal of the American Geriatrics Society. 2015;63(3):486-500. Epub 2015/03/11.
  16. Hovstadius B, Petersson G, Hellstrom L, Ericson L. Trends in inappropriate drug therapy prescription in the elderly in Sweden from 2006 to 2013: assessment using national indicators. Drugs & aging. 2014;31(5):379-86. Epub 2014/04/02.
  17. Schoenenberger AW, Stuck AE. Inappropriate drug use among older persons: is it time for action? Age and ageing. 2014;43(6):737-9. Epub 2014/10/11.
  18. Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation. . [cited 2013]; Available from: http://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation.

 

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Ah, school summer holidays! Childhood memories of endless sunny days (it only ever rained if you were caravanning or camping!), being out from dawn to dusk without a care in the world. Back to school with any number of adventures to relate…

But for some girls, the summer holiday will only bring traumatic memories and enduring pain and discomfort. These girls will have been taken to a foreign land, and will have been mutilated against their will.

Female Genital Mutilation (FGM) (also known as sunna or female circumcision) is traditionally performed by a woman with no medical training using knives, scissors, scalpels, pieces of glass or razor blades. Anaesthetics are generally not used. Unsurprisingly, girls may have to be forcibly restrained [1].

Which girls are at risk?

The World Health Organization (WHO) [2] states that Female Genital Mutilation  (FGM) procedures are mostly carried out on young girls sometime between infancy and age 15 [3].  More than 125 million girls and women alive today have been cut in the 29 countries in the western, eastern, and north-eastern regions of Africa, the Middle East and Asia where FGM is concentrated, and among migrants from these areas [2,3].

In the UK, it has been estimated that over 20,000 girls under the age of 15 are at risk of female genital mutilation (FGM) each year, and that 66,000 women in the UK are living with the consequences of FGM. However, the true extent is unknown, due to the “hidden” nature of the crime. UK communities that are most at risk of FGM include Kenyan, Somali, Sudanese, Sierra Leonean, Egyptian, Nigerian and Eritrean. Non-African communities that practise FGM include Yemeni, Afghani, Kurdish, Indonesian and Pakistani.

FGM is deeply rooted within many cultures; while many believe that FGM is a form of abuse and violence and a clear violation of human rights, for those practising it, it is  an act of love or a rite of passage, or in the daughter’s best interest [4].

Legal position

In England, Wales and Northern Ireland, the practice is illegal under the Female Genital Mutilation Act 2003 (this offence captures mutilation of a female’s labia majora, labia minora or clitoris), and in Scotland it is illegal under the Prohibition of Female Genital Mutilation (Scotland) Act 2005 [5].

Under the 2003 Act it is an offence in England, Wales and Northern Ireland for anyone (regardless of their nationality and residence status) to:

  • perform FGM in the UK
  • assist the carrying out of FGM in the UK
  • assist a girl to carry out FGM on herself in the UK
  • assist from the UK a non-UK person to carry out FGM outside the UK on a UK national or permanent UK resident

FGM and healthcare practitioners

Although not in place as yet, under the Serious Crime Act 2015, healthcare professionals have a mandatory reporting requirement; they will have to notify the police if they discover that an act of FGM appears to have been carried out on a girl aged under 18 years.

Your organisation will have a policy in place, and the document Multi-Agency Practice Guidelines. Female Genital Mutilation is an excellent resource which includes good practice (including medical examination), guidance for health professionals, identifying at-risk children, and a list of external agencies and charities for professionals and the public [5]. Specialist clinics (NHS) offer a range of healthcare services for women and girls who have been subjected to FGM, including reversal surgery [6].

The school summer holidays are commonly known as the ‘cutting season’ because this is when most girls are taken abroad and cut – the extended break gives them a chance to heal before they return to school. Girls may well present with infections or bleeding.

The implications of FGM for UK practitioners were bought into sharp relief earlier this year when after the CPS brought a failed prosecution attempt against a doctor they accused of illegally stitching back up a young mother after she gave birth thereby re-doing the mutilation she suffered as a six-year-old in Somalia [7].

Incidents such as this clearly highlight the need for comprehensive organisational guidance, policy and procedures, aligned with staff awareness of the practice.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. NHS Choices. Female Genital Mutilation. Available at:
    http://www.nhs.uk/Conditions/female-genital-mutilation/Pages/Introduction.aspx. Accessed July 2015
  2. World Health Organization. Female Genial Mutilation. Fact sheet No.241. Available at: http://www.who.int/mediacentre/factsheets/fs241/en/ Accessed July 2015
  3. UNICEF. Female Genital Mutilation/Cutting: a statistical overview and exploration of the dynamics of change. 2013. Available at:
    http://www.unicef.org/publications/index_69875.html. Accessed July 2015
  4. Royal College of Nursing. Female genital mutilation. An RCN resource for nursing and midwifery practice (Second edition). 2014. Available at:
    http://www.rcn.org.uk/__data/assets/pdf_file/0010/608914/RCNguidance_FGM_WEB2.pdf. Accessed July 2015
  5. HM Government. Multi-Agency Practice Guidelines. Female Genital Mutilation. 2014. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/380125/MultiAgencyPracticeGuidelinesNov14.pdf Accessed July 2015
  6. Department of Health. NHS Specialist Services for Female Genital Mutilation. 2014. Available at:
    http://www.nhs.uk/NHSEngland/AboutNHSservices/sexual-health-services/Documents/List%20of%20FGM%20Clinics%20Mar%2014%20FINAL.pdf
  7. The Telegraph (2015). NHS doctor cleared in less than 30 minutes in first FGM case. Available at: http://www.telegraph.co.uk/news/uknews/law-and-order/11390629/NHS-doctor-cleared-of-performing-FGM-amid-claims-he-was-used-as-a-scapegoat.html. Accessed July 2015

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