General Practice: Long-term conditions, multimorbidity and polypharmacy

🩺 Long-term conditions, multimorbidity and polypharmacy. Over a quarter of adults in England have two or more long-term conditions, rising to most people over 65. Long-term conditions account for about half of GP appointments and most NHS spending. Disease-specific details are in the specialty chapters; this chapter covers how chronic disease is run in primary care: registers and recall, structured reviews, targets and when to relax them, multimorbidity, frailty and safe prescribing.
Your four questions at every long-term condition review: Is the condition controlled, and are complications developing? Are the medicines still right, safe and being taken? What matters most to this person, and does the plan reflect it? What is the next review, and who is responsible?

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The Burden of Long-term Conditions

• A long-term condition cannot currently be cured but can be controlled with medicines and other treatment (e.g. diabetes, COPD, arthritis, hypertension, dementia).
• Prevalence rises steeply with age and deprivation - people in the most deprived areas develop multimorbidity 10–15 years earlier.
• Mental–physical comorbidity is common: depression is two to three times more common in people with long-term conditions and worsens outcomes.
• Treatment burden - appointments, tests, medicines and self-management tasks - can overwhelm patients and reduce adherence.

Organising Chronic Disease Care

• Disease registers (coded diagnoses) identify the population; recall systems invite patients for reviews.
• Chronic care model - informed, activated patients interacting with a prepared, proactive team; supported self-management; decision support; clinical information systems.
• Nurse-led clinics for diabetes, asthma, COPD and hypertension, with GP input for complex cases.
• Single combined annual review ("one-stop" or birthday-month review) for people with several conditions reduces repeated visits.
• Personalised care and support planning - the patient brings priorities and goals; the plan is written and shared.
• Self-management - education programmes (e.g. DESMOND for type 2 diabetes, pulmonary rehabilitation), home BP monitoring, asthma action plans, COPD rescue packs (for selected patients).
• Population health management - using data to target those at highest risk (e.g. risk stratification for unplanned admission).

The Structured Annual Review

Element	Content
Symptoms and control	Condition-specific questions (e.g. RCP 3 questions for asthma, CAT score for COPD)
Examination	BP, weight/BMI, pulse rhythm; feet in diabetes; inhaler technique
Tests	HbA1c, lipids, U&E/eGFR, urine ACR, TFTs as indicated
Complications	Eyes (retinal screening), feet, kidneys, CVD
Medicines	Adherence, side effects, interactions, deprescribing opportunities
Lifestyle	Smoking, alcohol, activity, diet, weight
Mental health	Screen for depression and anxiety
Vaccinations	Influenza, pneumococcal, COVID-19 (seasonal), RSV (eligible ages), shingles
Care planning	Goals, self-management, written plan, next review

Hypertension in Primary Care

• Diagnosis (NICE NG136): clinic BP ≥140/90 → confirm with ABPM (or HBPM) - daytime average ≥135/85 is hypertension.
• Assess target organ damage (urine ACR, U&E, HbA1c, lipids, ECG, fundi) and QRISK3 CVD risk.
• Treat stage 1 if under 80 with target organ damage, CVD, renal disease, diabetes or 10-year CVD risk ≥10%; treat all stage 2 (≥160/100 clinic, ≥150/95 ABPM).
• Step 1: ACE inhibitor/ARB if under 55 and not of Black African/African–Caribbean origin, or if diabetic; otherwise CCB. Step 2: add the other (or a thiazide-like diuretic). Step 3: ACEi/ARB + CCB + thiazide-like diuretic. Step 4: check adherence and BP, then spironolactone (if K⁺ ≤4.5) or alpha/beta-blocker; seek specialist advice.
• Targets (clinic): <140/90 if under 80; <150/90 if 80 or over; use clinical judgement in frailty and postural hypotension (measure standing BP).
• Same-day referral: BP ≥180/120 with papilloedema/retinal haemorrhage, or life-threatening symptoms (confusion, chest pain, heart failure, AKI); suspected phaeochromocytoma.

Type 2 Diabetes in Primary Care

• Diagnosis: HbA1c ≥48 mmol/mol (repeat if asymptomatic) or fasting glucose ≥7.0 / random ≥11.1 mmol/L with symptoms. HbA1c is unreliable in pregnancy, haemoglobinopathy, recent blood loss/transfusion, and some anaemias.
• Targets: HbA1c 48 mmol/mol on lifestyle or a single drug not causing hypoglycaemia; 53 mmol/mol if on drugs that cause hypoglycaemia; relax in frailty and limited life expectancy.
• Drug choice (NICE NG28): metformin first; consider an SGLT2 inhibitor with metformin in established CVD, heart failure, CKD or high CV risk. Further options: DPP-4 inhibitor, sulfonylurea, pioglitazone, GLP-1 receptor agonist (criteria including BMI), tirzepatide, insulin. Follow the current NICE pathway, which was revised in 2026.
• Annual care processes: HbA1c, BP, cholesterol, creatinine, urine ACR, foot check, BMI, smoking status, retinal screening (NHS Diabetic Eye Screening Programme), structured education.
• Foot risk - low, moderate, high, or active ulcer; active diabetic foot problem (ulcer, infection, ischaemia, Charcot) → same-day/next-day referral to the multidisciplinary foot service.
• Sick-day rules - temporarily stop SGLT2 inhibitors, metformin, ACEi/ARB, diuretics and NSAIDs during dehydrating illness; check ketones on SGLT2 inhibitors (risk of euglycaemic DKA); never stop insulin.
• Driving and DVLA: insulin users must meet DVLA rules (glucose testing, hypoglycaemia awareness).

Asthma and COPD Reviews

• Asthma (NICE/BTS/SIGN NG245, 2024): confirm diagnosis objectively (FeNO or blood eosinophils, then spirometry with bronchodilator reversibility, PEF variability or challenge testing). For age 12+: as-needed low-dose ICS/formoterol (AIR), then MART, rather than SABA-only treatment.
• Asthma review: symptoms (RCP 3 questions - night waking, daytime symptoms, activity limitation), SABA use (≥3 SABA prescriptions a year signals poor control and increased risk of death), exacerbations, inhaler technique, adherence, personalised action plan, smoking.
• COPD (NICE NG115): confirm with post-bronchodilator spirometry (FEV1/FVC <0.7). Review: smoking cessation (the single most effective intervention), vaccinations, pulmonary rehabilitation (MRC dyspnoea grade ≥3), inhaler choice (LAMA+LABA; triple therapy if asthmatic features or frequent exacerbations), oxygen assessment, self-management plan and rescue pack where appropriate, anxiety and depression.
• Inhaler technique is checked at every review and whenever control worsens; consider carbon footprint (dry-powder inhalers have lower emissions than pressurised MDIs).

Chronic Kidney Disease

• Definition: abnormal kidney structure or function for >3 months - eGFR <60 or ACR ≥3 mg/mmol, among other markers.
• Classification: by eGFR (G1–G5) and ACR (A1–A3). Test people with diabetes, hypertension, CVD, family history, structural renal disease or AKI.
• Management (NICE NG203): BP control (target <140/90; <130/80 if ACR ≥70), ACEi/ARB if ACR ≥3 with diabetes or ≥30 without; SGLT2 inhibitor (e.g. dapagliflozin) for CKD with diabetes or proteinuria per NICE; atorvastatin 20 mg for primary prevention; avoid nephrotoxins (NSAIDs); dose-adjust medicines.
• Refer if eGFR <30, ACR ≥70 (unless due to diabetes and treated), sustained fall in eGFR ≥25% with stage change or ≥15 in a year, poorly controlled hypertension on 4 drugs, or suspected genetic/rare cause. 5-year kidney failure risk >5% (Kidney Failure Risk Equation) is a referral trigger.

Cardiovascular Risk and Secondary Prevention

• QRISK3 estimates 10-year CVD risk for people aged 25–84 without CVD (not valid for type 1 diabetes, CKD stage 3+ or FH - these are treated anyway).
• Primary prevention (NICE NG238): offer atorvastatin 20 mg if QRISK3 ≥10% after lifestyle discussion (and consider statins below 10% if the person prefers); aim for >40% reduction in non-HDL cholesterol.
• Secondary prevention: atorvastatin 80 mg (lower dose if interactions or CKD); lipid-lowering targets LDL ≤2.0 mmol/L or non-HDL ≤2.6 mmol/L; add ezetimibe, then inclisiran or a PCSK9 inhibitor if criteria are met.
• After ACS: dual antiplatelet therapy (usually 12 months), ACEi, beta-blocker, statin, cardiac rehabilitation.
• Familial hypercholesterolaemia: suspect if total cholesterol >7.5 mmol/L with family history of premature CHD; use Simon Broome or Dutch Lipid Clinic criteria and refer for genetic testing and cascade testing.
• NHS Health Check - every 5 years for people aged 40–74 without existing CVD, diabetes, CKD or hypertension.

Atrial Fibrillation and Anticoagulation

• Opportunistic pulse palpation in people with symptoms or risk factors; ECG if irregular.
• Stroke risk: NICE NG196 (2021) uses CHA₂DS₂-VASc - offer anticoagulation if score ≥2, consider if ≥1 in men. Bleeding risk with ORBIT (NICE now prefers ORBIT to HAS-BLED); a high bleeding risk is a reason to correct modifiable factors, not to withhold anticoagulation.
• DOACs are first line (apixaban, edoxaban, rivaroxaban, dabigatran); warfarin if DOACs are contraindicated (e.g. mechanical valve, moderate–severe mitral stenosis).
• DOAC monitoring: creatinine clearance (Cockcroft–Gault), FBC, LFTs, weight at least annually - more often if older, frail or CrCl <60.
• Rate control (beta-blocker or rate-limiting CCB; digoxin if sedentary) is first line for most; refer for rhythm control if symptoms persist, new-onset AF, reversible cause, or heart failure caused by AF.
• Falls alone are rarely a reason not to anticoagulate.

Hypothyroidism and Other Monitored Conditions

• Hypothyroidism: levothyroxine 1.6 micrograms/kg/day in younger adults; start 25–50 micrograms in older people or those with heart disease. Check TSH 6–8 weeks after a dose change, then annually. Target TSH within the reference range.
• Subclinical hypothyroidism - consider treatment if TSH ≥10 (or symptoms in younger people); avoid overtreatment in older people (AF, osteoporosis).
• Gout - treat to target urate <360 µmol/L (<300 if tophi) with allopurinol, titrated monthly; consider prophylactic colchicine or NSAID for the first months.
• Osteoporosis - FRAX/QFracture risk, DEXA, bisphosphonate review after 5 years (3 years for zoledronate), drug holiday if risk falls; never stop denosumab without follow-on therapy.
• Epilepsy - annual review, seizure frequency, driving, contraception and valproate pregnancy prevention programme.
• Severe mental illness - annual physical health check (BMI, BP, lipids, HbA1c, smoking, alcohol) - life expectancy is 15–20 years shorter.

Multimorbidity (NICE NG56)

• Multimorbidity = two or more long-term conditions; complex multimorbidity = many conditions with high treatment burden.
• Guidelines are written for single diseases - applying all of them to one patient creates polypharmacy and unachievable regimens.
• NICE NG56 approach - identify those who would benefit (frailty, multiple drugs, unplanned care, treatment burden, mental health conditions), then:
  • Discuss the purpose of an approach to care that takes account of multimorbidity.
  • Establish disease and treatment burden.
  • Establish the patient's goals, values and priorities.
  • Review medicines and other treatments - consider stopping those with limited benefit (use absolute risk and time-to-benefit).
  • Agree an individualised management plan, with a named coordinator.
• Time to benefit - statins take 2–5 years to prevent events; tight glucose control 8+ years; these matter when life expectancy is short.

Frailty in the Community

• Frailty - loss of physiological reserve, leaving the person vulnerable to sudden decline after a minor stressor (infection, new drug, fall).
• Identification: electronic Frailty Index (eFI) in GP records (fit, mild, moderate, severe), Clinical Frailty Scale (CFS 1–9), gait speed, Timed Up and Go, PRISMA-7.
• Presentations ("frailty syndromes"): falls, immobility, delirium, incontinence, susceptibility to drug side effects.
• Community management: Comprehensive Geriatric Assessment (medical, functional, psychological, social, environmental), strength and balance exercise, nutrition, medication review, advance care planning, carer support, falls prevention.
• Moderate–severe frailty - annual medication review and falls assessment are contractual expectations in England.

Polypharmacy and Deprescribing

• Problematic polypharmacy - inappropriate medicines, or intended benefit not realised; risk rises with number of drugs (≥10 drugs greatly increases adverse drug reactions and admissions).
• Tools: STOPP/START criteria, Beers criteria, anticholinergic burden scales (ACB), NO TEARS, the Scottish 7-steps polypharmacy model (aims, need, effectiveness, safety, cost-effectiveness, adherence/patient-centredness).
• Common deprescribing targets: PPIs without ongoing indication, long-term benzodiazepines and Z-drugs, antipsychotics in dementia, anticholinergics (oxybutynin, TCAs), aspirin for primary prevention, sulfonylureas/insulin causing hypoglycaemia in frailty, antihypertensives with postural hypotension, bisphosphonates beyond 5 years without review.
• Prescribing cascade - a side effect is mistaken for a new condition and treated with another drug (e.g. amlodipine → ankle oedema → furosemide; donepezil → incontinence → oxybutynin).
• Deprescribe gradually where withdrawal effects are possible (beta-blockers, benzodiazepines, antidepressants, opioids, gabapentinoids, PPIs), with monitoring and a plan to restart if needed.

High-risk Drug Monitoring

Drug	Key monitoring
Methotrexate	FBC, LFT, U&E every 1–2 weeks until stable, then every 3 months; weekly dosing - name the day; folic acid on a different day
Lithium	Level 12 h post-dose every 3 months (target usually 0.4–1.0 mmol/L); U&E, eGFR, calcium, TFTs every 6 months
Warfarin	INR per anticoagulation service; interactions (antibiotics, azoles, amiodarone)
DOACs	Renal function (CrCl), FBC, LFT at least annually
Amiodarone	TFTs and LFTs every 6 months; CXR and PFTs if symptomatic
ACEi/ARB/spironolactone	U&E 1–2 weeks after starting or increasing; accept creatinine rise ≤30% (or eGFR fall ≤25%)
Azathioprine	TPMT before starting; FBC, LFTs per shared care
Antipsychotics	Weight, lipids, glucose/HbA1c, prolactin, ECG (some agents)
Valproate (women and girls)	Pregnancy Prevention Programme; annual specialist review

• Rule of thumb: a drug that needs monitoring should not be issued if monitoring is overdue - contact the patient.

Long-term Conditions at a Glance

Condition	Key primary care targets
Hypertension	<140/90 (under 80); <150/90 (80+); ABPM to diagnose
Type 2 diabetes	HbA1c 48 or 53; annual eyes, feet, ACR
Asthma	AIR/MART; action plan; SABA overuse = danger sign
COPD	Stop smoking; pulmonary rehab; vaccinations
CKD	BP, ACEi/ARB, SGLT2i, statin; refer eGFR <30 or ACR ≥70
CVD prevention	QRISK3 ≥10% → atorvastatin 20 mg; secondary → 80 mg
AF	CHA₂DS₂-VASc ≥2 → DOAC; ORBIT for bleeding risk

Spot the Answer

• A 79-year-old on 14 medicines has falls, confusion and constipation. → Problematic polypharmacy and anticholinergic burden - structured medication review using STOPP/START.
• Ankle swelling appears after amlodipine is started, and furosemide is added. → Prescribing cascade.
• An asthmatic adult collects 8 salbutamol inhalers a year. → Poor control and high risk of fatal asthma - urgent review, ICS-based treatment.
• eGFR 25 and ACR 80 in a 60-year-old. → Refer to nephrology.
• A 76-year-old with AF, hypertension and diabetes but recurrent falls. → CHA₂DS₂-VASc 4 - anticoagulate; address falls risk.

Exam-style Scenarios

• Scenario. A 58-year-old with type 2 diabetes on metformin has HbA1c 62 mmol/mol, eGFR 52, ACR 12 mg/mmol and a previous MI.
  Answer: Add an SGLT2 inhibitor (cardiorenal benefit), ensure ACEi/ARB at maximum tolerated dose, high-intensity statin, BP target, sick-day rules and annual checks.
• Scenario. An 88-year-old with moderate dementia, CFS 7, is on atorvastatin, alendronate (8 years), aspirin (no vascular disease), omeprazole (no indication) and gliclazide with HbA1c 46.
  Answer: Prioritise deprescribing with the patient/family: stop aspirin, review omeprazole (step down/stop), stop gliclazide (hypoglycaemia risk; target can be relaxed), review the bisphosphonate (holiday), and discuss the statin in the context of goals and life expectancy.
• Scenario. A practice audit shows only 55% of patients on lithium have had a level in the last 3 months.
  Answer: Set a standard (e.g. 100% per NICE/BNF), identify causes, introduce recall and prescription controls (no issue if monitoring is overdue), then re-audit - completing the audit cycle.

Key Points

• Registers, recall and structured reviews underpin chronic disease care.
• Targets are tools, not goals - individualise for frailty and patient priorities.
• Multimorbidity needs one coordinated plan, not a set of single-disease guidelines.
• Polypharmacy causes harm; deprescribing is an active, planned intervention.
• Never issue a high-risk drug when its monitoring is overdue.

Guidelines and Further Reading

• NICE NG56: Multimorbidity - clinical assessment and management
• NICE NG5: Medicines optimisation
• NICE NG136 (hypertension); NG28 (type 2 diabetes); NG245 (asthma); NG115 (COPD); NG203 (CKD); NG238 (CVD risk and lipids); NG196 (AF)
• STOPP/START criteria (version 3, 2023); Scottish Government Polypharmacy Guidance (7 steps)
• British Geriatrics Society: Fit for Frailty
• BNF - for current doses and monitoring