LESSON 4.3: Managing Multi-Morbidity & Polypharmacy

LESSON 4.3: Managing Multi-Morbidity & Polypharmacy

One in four UK adults lives with two or more long-term conditions. Over two million adults take seven or more prescribed medications daily. Multi-morbidity is not the exception in general practice — it is the norm. The SCA will test whether you can manage the whole patient, not just the presenting complaint in isolation. A candidate who treats a new knee pain without considering the patient's existing diabetes, hypertension, and NSAID-sensitive kidneys is not consulting safely — and the examiner will see it.

Why This Matters for Your Score

Multi-morbidity cases test all three domains simultaneously. Data Gathering: did you explore the wider medical context, not just the presenting symptom? Clinical Management: did your plan account for existing conditions, current medications, and interactions? Relating to Others: did you involve the patient in prioritising what matters most to them, rather than imposing your own agenda?

How the Presenting Problem Interacts with Existing Conditions

Every new symptom and every new prescription exists in the context of what is already there. Train yourself to think in layers:

1. A patient with depression presenting with chronic pain — are the two connected? Will an antidepressant that also treats neuropathic pain (e.g., amitriptyline, duloxetine) address both?
2. A patient with COPD presenting with anxiety — could their salbutamol overuse be driving the anxiety symptoms? Could their anxiety be worsening their breathlessness perception?
3. A patient with diabetes presenting with a foot ulcer — this is not just a wound. It involves vascular assessment, neuropathy screening, infection risk, glucose optimisation, and possibly urgent referral
4. A patient with heart failure presenting with knee pain — you cannot reach for an NSAID. What are your alternatives? Paracetamol, topical treatments, physiotherapy, or careful short-course options with renal monitoring

The examiner is watching for whether you connect the dots. A candidate who prescribes ibuprofen for knee pain without noticing the patient is on an ACEi with borderline renal function has made a dangerous error. A candidate who says "I'd normally suggest an anti-inflammatory, but given your kidney function and blood pressure medication, I think we should go a different route" demonstrates exactly the reasoning the RCGP wants to see.

Drug Interactions and Prescribing Safely

Without the BNF available, you need to carry the most important interactions in your head. You do not need to know every interaction — but you must know the common, dangerous ones:

1. NSAIDs + ACEi/ARBs + diuretics — the "triple whammy" for acute kidney injury
2. Warfarin + antibiotics (especially macrolides and metronidazole) — increased bleeding risk
3. SSRIs + NSAIDs — increased GI bleeding risk
4. Methotrexate + trimethoprim — potentially fatal bone marrow suppression
5. Opioids + gabapentinoids — respiratory depression risk (MHRA safety alert)
6. QT-prolonging drugs in combination — macrolides, antipsychotics, certain antiemetics

When prescribing in a multi-morbidity case, verbalise your thinking: "I'm mindful that you're already on [medication], so I want to make sure anything new doesn't interact with that." This scores marks even if you are not certain of the exact interaction — it shows the examiner you are thinking about safety.

The Burden of Treatment

Multi-morbid patients do not just carry the burden of their illnesses — they carry the burden of managing them. Multiple appointments, multiple medications with different dosing schedules, blood test monitoring, dietary restrictions, self-monitoring tasks, and the cognitive load of keeping track of it all. This burden is itself a clinical problem.

1. Ask about it directly: "I know you've got a lot of medications to manage. How are you finding that? Is it feeling overwhelming?"
2. Consider simplification: can any medications be combined or rationalised? Can monitoring intervals be aligned? Can a medication with multiple benefits replace two separate ones?
3. Be realistic about adherence: a patient who is prescribed eight medications but only takes four is not non-compliant — they are overwhelmed. Work with them to identify which ones matter most

Deprescribing: When Stopping Is the Best Management

Not every consultation should end with a new prescription. In multi-morbidity, some of the best management involves removing medications that are no longer helping, no longer indicated, or causing more harm than benefit.

1. Proton pump inhibitors prescribed years ago for a short-term indication and never reviewed
2. Bisphosphonates that have been running beyond the recommended treatment duration
3. Antihypertensives in an elderly patient whose blood pressure is now too low, causing falls
4. Opioids for chronic pain that are not reducing pain but are causing constipation, drowsiness, and dependence

Verbalise this reasoning: "Looking at your medication list, I actually think we might benefit from stopping [medication]. It was started a while ago for [reason], and I'm not sure it's still helping. Removing it could reduce your side effects and simplify things. What do you think?"

Patients often expect to leave with a new prescription. Framing deprescribing as active, positive management — rather than "taking something away" — helps them accept it: "I'm not giving up on this. I'm actually giving you better care by removing something that's not working for you."

Discussing Priorities with the Patient

A patient with five active problems cannot have all five optimally managed in a single 12-minute consultation. The skill is in negotiating priorities collaboratively — not unilaterally deciding what matters.

1. "You've got a lot going on. What matters most to you right now?"
2. "If we could improve one thing today, what would make the biggest difference to your life?"
3. "I'd like to focus on your diabetes review today because your last blood test showed some changes — but I also want to make sure we're not ignoring anything that's worrying you. What's your priority?"

This is shared decision-making at its most important — and it scores heavily on both Clinical Management and Relating to Others.