Okeowo Daniel, Patterson Alastair, Boyd Cynthia, Reeve Emily, Gnjidic Danijela, Todd Adam
School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Ther Adv Drug Saf. 2018 Sep 12;9(11):619-630. doi: 10.1177/2042098618795770. eCollection 2018 Nov.
The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped.
Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI).
The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication.
In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
本研究的目的是：（1）将当前英国国家卫生与临床优化研究所（NICE）的临床实践指南应用于一位患有多种疾病且病情危及生命的老年假设患者；（2）考虑NICE指南中与多种疾病特别相关的内容如何影响治疗选择；以及（3）确定此类临床实践指南是否描述了药物应如何以及何时进行审查、减量和停用。
基于老年人常见的长期病症构建了一位老年假设患者。将相关的NICE指南应用于该假设患者，以确定在三种治疗模式下应启动何种药物治疗：新患者模式、难治性治疗模式和最后一线治疗模式。根据药物治疗方案复杂性指数（MRCI）评估每种模式下的药物治疗复杂性。
大多数指南建议在该假设患者中启动药物治疗；如果初始治疗方法不成功，各指南都主张使用更多药物，治疗方案会变得越来越复杂。在新患者模式下，每天将启动4种不同的药物（9个剂量单位）；在难治性治疗模式下，6种不同的药物（15个剂量单位）；在最后一线治疗模式下，11种不同的药物（20个剂量单位）。用于该假设患者的指南均未讨论停药方法。
在英国，针对特定疾病的临床实践指南通常主张启动药物治疗以管理长期病症，在不同的治疗阶段药物治疗方案会变得越来越复杂。对于患有危及生命疾病和多种疾病的老年人，往往缺乏具体的治疗建议信息。虽然指南经常解释药物应如何以及何时启动，但通常没有关于药物应何时以及如何减量或停用的信息。
