Stopping the 'prescribing cascade' to protect Australians

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One of Australia’s peak medical bodies is calling on medical professionals to stop a “prescribing cascade” of medications which it says is creating avoidable risks for some patients.

The Royal Australasian College of Physicians (RACP) has released new guidelines to help reduce “concerning” practices of overprescription.

“Overprescription is creating avoidable risks. This is especially true for older patients,” RACP president and clinical pharmacologist professor Jennifer Martin said in a statement on Thursday.

Martin told SBS News this is a “big problem” in Australia, with increasing data showing older people are on a large number of medications, which can put them at increased risk of harm.

Andrew McLachlan, head of school and dean of pharmacy at the University of Sydney, said there have been growing concerns in recent years about the inappropriate use of some medicines — and the general trend that people are using more medicines.

Almost 40 per cent of Australians aged 75 and over were prescribed more than five medicines at the same time, according to 2021 data from the Australian Commission on Safety and Quality of Health Care (ACSQHC).

This refers to the concept of polypharmacy, which is the concurrent use of multiple medicines — and is common in older people who often have several chronic diseases requiring treatment.

“That doesn’t necessarily mean that’s a bad thing. They [the medications] could be appropriate for the health conditions that those people have,” McLachlan said.

“But what we are seeing globally is an increase in preventable harms from medicines.”

According to the ACSQHC, polypharmcy can increase the risk of harm from medicines due to a greater chance of interaction between medicines, with older people also being more sensitive to their effects.

In 2017, the World Health Organization launched an initiative called Medication Without Harm, which aimed to reduce severe, avoidable medication-related harm by 50 per cent globally over five years.

“I think these recommendations really align with that global trend to make sure that we’re using medicines for benefit and managing and reducing the possible risks or harmful effects of those medicines,” McLachlan said.

Dr Sajal Saha, a research fellow at Deakin University’s school of medicine, researches antibiotic use. He said the guidelines are “timely and critical” in response to the “overuse and misuse” of medicines in Australia.

Citing the ACSQHC 2021 research, he said an estimated 30 to 50 per cent of antibiotic prescriptions in Australia are inappropriate either in choice, dose or duration.

“This is a global public health program. To mitigate those issues, these guidelines will have a significant impact in changing the practice and policies in Australia,” he said.

A ‘prescription cascade’

The RACP developed the guidelines in conjunction with the Australian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT).

Martin said the guidelines target all Australians, “but the problem is much bigger in the older population”.

“Many patients experience a ‘prescribing cascade’, where the side effects of one medicine can be misdiagnosed as a new condition, which may in turn lead to further unnecessary prescriptions,” she said.

“This idea of a prescribing cascade may be attributed to some of the challenges in our health system that don’t always allow a comprehensive history, and the detective work needed to understand what might be contributing to a presentation to the health system,” McLachlan said.

He stressed medicines are “the most common and successful intervention” that we have in the health system.

“It’s not unreasonable that a medicine would be used to prevent or treat a health problem. The focus here is about the appropriate and safe use of those medicines — and part of that means we need to have all the relevant information about the person.”

Part of the challenge is the pace of healthcare and the demands on the system, McLachlan said.

Saha agreed, pointing to different challenges and “gaps” in hospital and community settings.

The RACP is calling on medical professionals to rethink how and when they prescribe medications to patients.

“It is vital that medical professionals prioritise safer non-medication treatments when they’re equally or more effective and only prescribe medications when required,” Martin said.

ASCEPT President Associate Professor Bridin Murnion said the recommendations also address the risks associated with “off-label” prescribing — where medicines are prescribed for purposes outside of approved conditions from the Therapeutic Goods Administration.

“Medical professionals are urged to consider the ethical and legal issues linked with off-label medicine use, especially in cases where there’s insufficient evidence,” Murnion said.