(Disclaimer: Content provided below is for informational purposes only and does not constitute medical advice.)

Some of the quotes by Sir William Osler have come to mean so much as I have grown as a physician. Two of my favorite quotes in the context of this post are:

 

“The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.” –Sir William Osler

“One of the first duties of the physician is to educate the masses not to take medicines.” –Sir William Osler

 

As doctors, we always want to do “something” to care for patients. The desire to do something is even more when we are uncertain about what is going on with patient. Also, patients expect something to be done when they have a problem. Either they take a medicine prescribed by doctor or tend to self-medicate.

Recently, I saw an elderly lady in her 70s with complains of leg pains, weakness, skin infection and some burning with urination. She is also a diabetic on insulin and takes some oral medications for diabetes for past 15 years or so. As a part of her medical history, I went over her medications and realized she was on 4 medicines for diabetes (3 oral + insulin), aspirin and a statin for prevention of heart attack, a multivitamin, pregabalin and NSAIDs for leg pain. She suffered from frequent “acidity problems” and took an antacid off and on. Because her sugars were still not well controlled, she suffered from recurrent infections of skin and urinary tract and was on antibiotics off and on. In short, she was almost on a dozen medicines!

Definition of Polypharmacy:

Polypharmacy is when too many forms of medication are used by a patient, more drugs are prescribed than clinically warranted, or even when all prescribed medications are clinically indicated, but there are too many to take. Simplistically, polypharmacy is defined as use of 5 or more medications.

Prescription cascade: Prescribing cascade occurs when a new drug is prescribed to treat symptoms arising from an unrecognized adverse drug event related to an existing therapy.

For example, in the above mentioned case, the patient is on more than 10 medications and multiple forms of medications. She is on multivitamins and NSAIDS that can cause gastritis and on antacids to treat her GI symptoms.

Unfortunately, patients like her are the typical geriatric patients I come across in my practice. This is polypharmacy and prescription cascade!

Why should we care?

  1. Adverse drug reactions: Polypharmacy causes adverse drug reactions (ADRs). Adverse drug reactions occur because of drug interactions and can lead to increased illness, suffering and death. The rate of drug interactions increase exponentially with increase in the number of drugs. I have discussed basics of drug interactions here.
    The risks of negative interactions increase exponentially as the number of medications increase. In elderly, the risk of an adverse drug effect is 13% with the use of two medications, but with five medications, it increases to 58%. If seven or more medications are used, the incidence increases to 82%.
  1. Quality of life: Polypharmacy affects quality of life. Can you imagine being a patient taking more than 10 medicines with multiple times a day dosing?
  2. Increased cost: Polypharmacy increases the cost to patients/ healthcare system.
  3. Medication Adherence: Use of multiple medications lead to problems with medication adherence.

What are risk factors for polypharmacy and who is at risk?

Healthcare providers/system: Lack of skills and knowledge of prescribing healthcare provider, lack of guidelines, inappropriate unethical promotion of medicines by pharmaceutical companies, unrestricted availability of medicines,

Patients: Elderly patients, patients with multiple comorbidities, self-medication, patients with chronic medical problems, patients with psychiatric disorders, hospitalized patients and patients who see multiple doctors are at increased risk for polypharmacy.

What medications are problematic?

Especially in elderly,  Beer’s criteria are widely used (initially developed by an expert consensus panel in 1991 and the 2012 revised Beers criteria are available through the American Geriatrics Society website). Also, medications with narrow therapeutic index (e.g. warfarin, digoxin, etc) and high risk medications need closer monitoring when used with along with several medications.

Practical Strategies to avoid Polypharmacy

  1. Review current medications, and not just the ones prescribed by you. Educate your patient to bring all the medications from all the doctors and the dangers of polypharmacy. Assess for medication adherence or any adverse drug effects patient may be experiencing.
  2. Use EMR/ technology solution to make the list of all medications (generic names) along with the indication next to the medicine. This reduces the chances of duplication and drug-drug interactions.
  3. Discontinue unnecessary medications. Review the risk-benefit ratio.
  4. Consider non-pharmacologic options whenever possible. Use lifestyle modifications and dietary interventions as a first intervention wherever indicated.
  5. Use safer alternatives. Especially in elderly, certain medications are more likely to cause adverse reactions. Check out Beer’s list. Drugs with narrow therapeutic index need closer monitoring e.g. digoxin, warfarin etc
  6. Reduce dose when possible and simplify the dosing schedule; e.g. Remember that elderly have unique pharmacokinetics andyou may need to adjust the dose of medication based on creatinine clearance/ liver function. Whenever possible use medications with once a day dosing regimen.
  7. Educate the patient that vitamin/nutritional supplements/herbal medicines may interact with the patient’s medications as well and include them in the medication list. Educate patients about the risks of self-medication.
  8. Assess the functional status of patient- cognitive function, dexterity etc before prescribing.

ARMOR (Assess, Review, Minimize, Optimize, Reassess) is a tool to approach polypharmacy in a systematic and organized fashion.

 Summary

Polypharmacy can be dangerous. However, polypharmacy is inevitable at times because of multiple medical conditions. Appropriate polypharmacy may be beneficial if appropriateness of medication prescribed is taken into consideration.
Elderly are at a particular risk because they are more likely to have multiple medical conditions requiring medications.
When it comes to prescribing, remember the principle “keep it simple”. It is important to find the balance between aggressively treating diseases and avoiding medication-related harm.
Patient education is important to reduce adverse drug effects from polypharmacy.

References

  1. Interventions to improve the appropriate use of polypharmacy for older people  www.thecochranelibrary.com/details/file/841535/CD001095.html
  2. ARMOR- A tool to evaluate polypharmacy in elderly
    www.champ-program.org/static/ARMOR%20tool_Haque.pdf
  3. American Geriatric Society – Beer’s list
    http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf