Introduction: Heart failure (HF) is a complex condition often accompanied by comorbidities such as renal dysfunction, diabetes mellitus (DM), chronic respiratory diseases, frailty, and anaemia, necessitating intricate management involving multiple therapeutics. Objectives: This retrospective cohort study aims to characterize prescribing patterns and identify potentially inappropriate polypharmacy in individuals with HF and multimorbidity. Methods: Data was collected from 234 HF adults with multimorbidity under the care of the HF multidisciplinary team at Liverpool University Hospital Foundation Trust (LUHFT) from January 2020 -February 2021. Results: The mean age was 71.5±13.9 and 44% were female. ACCI was 6.9±3.3, CFS was 5.5±3.2, polypharmacy burden was high at 10.2±3.9, and ACB was 1.45±0.9. ACB was higher in those with CFS≥6 vs. those with CFS<6 (1.5±1.1 vs. 1.1±0.9; p=0.02). The proportion of adults with HF on treatment for depression was 19.7%, chronic pain 35%, and chronic constipation 19.7%. Fifteen percent received oral iron instead of the appropriate intravenous iron replacement, while 17.9% of the cohort were observed to be nearing the end of their lives. Regarding PIM use, 9% were on either DAPT/anticoagulant plus anti-platelet therapy beyond 12 months of an acute coronary event. One in five patients received PPIs without clear justification. Conclusion: Adults with frailty and HF have a higher ACB. This study identifies targets for de-prescribing interventions in HF, including inappropriate PPI and DAPT/anticoagulant plus anti-platelet therapy, which are seeing in 1:5 and 1:10 adults with HF in the clinic, respectively. Tailored guidelines can aid shared decision-making, reducing drug-related complications in this group.

IntroductionMultiple Sclerosis (MS) is a chronic autoimmune disorder causing nerve sheath demyelination and symptoms such as muscle weakness, mobility decline, and lack of coordination 1,2, generating unique health challenges and an economic burden 3-5. Patients experience reductions in bone and skeletal muscle mass6, muscle strength and function 7,8, and increased fracture risk 9, negatively impacting quality of life 10. Lower limb strength impairments8, poor balance 11 and spasticity12 also contribute to a lower quality of life10. Pharmacological treatments have been the primary option for patients with MS 13.Recent research has explored non-pharmacological treatments such as exercise, nutritional supplementation, and improved sleep quality14-21. Resistance exercise (RE) is particularly beneficial for MS rehabilitation, as it improves muscle strength and function, mobility, quality of life 22,23, and the immune system 24. High-dose vitamin D supplementation raises interleukin-10 (IL-10) levels in MS patients19, who tend to have lower levels of IL-10, which may contribute to the disease’s development 25. However, RE and vitamin D may not always improve physical fitness20,21. This could be due to unsatisfactory energy and protein intake, containing essential amino acids (EAA), which are necessary to stimulate muscle protein synthesis (MPS) and ultimately address sarcopenia 26, a condition prevalent in MS patients 27. EAA-based supplements enriched with L-leucine increase protein intake and optimise MPS in healthy older adults without compromising total energy intake during mealtimes28,29 and plasma EAA concentration is associated with muscle function in older women in the community 30. A higher protein intake, including specific amino acids, may positively impact bone health through mechanisms such as increasing insulin-like growth factor 1 (IGF-1) 31,32. Therefore, addressing dietary protein deficiencies alongside RE may optimise musculoskeletal health and function in female MS patients. This case study evaluated the effects of a 24-week home-based intervention, including EAAs and vitamin D3 supplementation, on muscle, bone, muscle strength, and function in a female patient with MS.