Polypharmacy

Polypharmacy is the use of four or more medications by a patient, generally adults aged over 65 years.[1][2][3][4] Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes.[5] About 21% of adults with intellectual disability are also exposed to polypharmacy.[6]

The United States (U.S.) and other countries are experiencing a fast growth of the older population, 65 years and older.[7][8] This growth is a result of the baby-boomer generation getting older and an increased life expectancy as a result of ongoing improvement in health care services worldwide.[9][10]

Concerns about polypharmacy include increased adverse drug reactions, drug interactions, prescribing cascade and higher costs.[11] Polypharmacy is often associated with a decreased quality of life, decreased mobility and cognition.[2]

It is well accepted in pharmacology that it is impossible to accurately predict the side effects or clinical effects of a combination of drugs without studying that particular combination of drugs in test subjects. Knowledge of the pharmacologic profiles of the individual drugs in question does not assure accurate prediction of the side effects of combinations of those drugs.

Whether or not the advantages of polypharmacy (over monotherapy) outweigh the disadvantages or risks depends upon the particular combination and diagnosis involved in any given case.[12] The use of multiple drugs, even in fairly straightforward illnesses, is not an indicator of poor treatment. A perfectly legitimate treatment regimen could include, for example, the following: a statin, an ACE inhibitor, a beta-blocker, aspirin, paracetamol and an antidepressant in the first year after a myocardial infarction.[13]

Medical uses

Considerations often associated with thoughtful, therapeutic polypharmacy include:

  1. Drugs given for a single somatic locale act on biochemical mechanisms present throughout the body such that their nonlinear interactions can produce an (unknown except empirically) global physiological state of health;[14]
  2. The more independent variables, "handles", to manipulate, the greater the likelihood of finding and stabilizing a small available parametric space of healthy function while minimizing unwanted effects.[15]

Often certain medications can interact with others in a positive way specifically intended when prescribed together, to achieve a greater effect that any of the single agents alone. This is particularly prominent in the field of anesthesia and pain management - where atypical agents such as antiepileptics, antidepressants, muscle relaxants, NMDA antagonists, and other medications are combined with more typical analgesics such as opioids, prostaglandin inhibitors, NSAIDS and others. This practice of pain management drug synergy is known as an analgesia sparing effect.

As another example, in anesthesia (particularly IV anesthesia and general anesthesia) multiple agents are almost always required - including hypnotics or analgesic inducing/maintenance agents such as Versed or Diprivan, usually an opioid analgesic such as morphine or Demerol, a paralytic such as vecuronium, and in inhaled general anesthesia generally a halogenated ether anesthetic such as sevoflurane or desflurane.

Contraindications

The use of polypharmacy is correlated to the use of potentially inappropriate medications. Potentially inappropriate medications are generally taken to mean those that have been agreed upon by expert consensus, such as by the Beers Criteria. These medications are generally inappropriate for older adults because the risks outweigh the benefits. Examples of these include urinary anticholinergics, which can prevent up to one episode of incontinence every 48 hours on average. However, they can also cause constipation, dry eyes, dry mouth, impaired cognition, and increase the risk of falls.

Polypharmacy is associated with an increased risk of falls in the elderly. Certain medications are well known to be associated with the risk of falls, including cardiovascular and psychoactive medications. The use of four or more of these medicines is known to be associated with a significantly higher, cumulative risk of falls. Although often not practical to achieve, withdrawing all medicines associated with falls risk can halve an individual's risk of future falls.

Every medication has potential adverse side-effects. With every drug added, there is an additive risk of side-effects. Also, many medications have potential interactions with other substances. 15% of older adults are potentially at risk for a major drug-drug interaction.[16] When a new drug is prescribed, the risk of interactions increases exponentially. Doctors and pharmacists aim to avoid prescribing medications that interact; often, adjustments in the dose of medications need to be made to avoid interactions, such as with warfarin, as it may lose its effect.

Special populations

Patients at greatest risk for negative polypharmacy consequences include the elderly, psychiatric patients, patients taking five or more drugs concurrently, those with multiple physicians and pharmacies, recently hospitalized patients, individuals with concurrent comorbidities,[17] low educational level,[18] and those with impaired vision or dexterity.

It is not uncommon for those dependent or addicted to substances to enter or remain in a state of polypharmacy misuse. Note, however, that the term polypharmacy and its variants generally refer to legal drug use as-prescribed, even when used in a negative or critical context.

Measures can be taken to limit polypharmacy to its truly legitimate and appropriate needs. This is an emerging area of research, frequently called deprescribing.[19] This reduction in medications has been shown to reduce the number of medications and is safe as it does not significantly alter health outcomes.[20] Clinical pharmacists can perform drug therapy reviews and teach physicians and their patients about drug safety and polypharmacy, as well as collaborating with physicians and patients to correct polypharmacy problems. Similar programs are likely to reduce the potentially deleterious consequences of polypharmacy. Such programs hinge upon patients and doctors informing pharmacists of other medications being prescribed, as well as herbal, over-the-counter substances and supplements that occasionally interfere with prescription-only medication.

Pill burden

Pill burden is a term that refers to the number of pills (tablets or capsules, the most common dosage forms) that a patient takes on a regular basis, along with all associated efforts that increase with that number - like storing, organizing, consuming, and understanding the various medications in one's regimen.

High pill burden decreases compliance with drug therapy, resulting from the need to take a large quantity of pills or other forms of medication on a regular basis. It also increases the possibility of adverse medication reactions (side effects) and drug-drug interactions. High pill burden has also been associated with an increased risk of hospitalization, medication errors, and increased costs for both the pharmaceuticals themselves and for the treatment of adverse events. Finally, pill burden is a source of dissatisfaction for many patients.

High pill burden was once commonly associated with antiretroviral drug regimens to control HIV, but now is more often seen in other patient populations. For instance, adults with multiple common chronic conditions such as diabetes, hypertension, lymphedema, hypercholesterolemia, osteoporosis, constipation, and clinical depression can often be prescribed more than a dozen different medications daily. The adverse reactions of these combinations of drugs are not reliably predictable. Obesity is implicated in many of the aforementioned conditions, and it is not uncommon for a clinically obese patient to receive pharmacologic treatment for all of these. Because chronic conditions tend to accumulate in the elderly, pill burden is a particular issue in geriatrics.

Reducing pill burden is recognized as a way to improve medication compliance. This is done through "deprescribing", where the risks and benefits are weighed when considering whether to continue a medication.[21] This includes drugs such as bisphosphonates (for osteoporosis) where it is often used indefinitely although there is only evidence to use it for five to ten years.[21]

The selection of long-acting active ingredients over short-acting ones may also reduce pill burden. For instance, ACE inhibitors are used in the management of hypertension. Both captopril and lisinopril are examples of ACE inhibitors. However, lisinopril is dosed once a day, whereas captopril may be dosed 2-3 times a day. Assuming that there are no contraindications or potential for drug interactions, using lisinopril instead of captopril may be an appropriate way to limit pill burden.

Interventions

The most common intervention in polypharmacy patients is deprescribing, which includes the identification and discontinuance of medications when the benefit no longer outweighs the harm. In elderly patients, this can commonly be done as a patient becomes more frail and treatment focus needs to shift from preventative to palliative.[22]

Several tools exist to help physicians decide when to deprescribe and what medications can be added to a pharmaceutical regimen. The Beers Criteria and the STOPP/START criteria help identify medications that have the highest risk of adverse drug events (ADE) and drug-drug interactions. PRIMA-eds is an algorithm that takes many patient factors into its calculations and can offer medication and dosing recommendations to the provider. Parameters of PRIMA-eds include diagnoses, medications, ADEs, symptoms, body mass index, vital signs, laboratory results, and medical studies performed in the elderly.[23]

A team approach is a relatively new method gaining popularity due to its effectiveness in managing patient care and obtaining the best outcomes. A team can include a primary provider, pharmacist, nurse, counselor, physical therapist, chaplain and others involved in patient care. Combining the ideas and points of view of the different providers allows a more holistic approach to the health of a patient. In 2013, the United States legislature mandated that every Medicare D patient receive an annual Medication Therapy Management (MTM) review by a team of healthcare professionals.[24]

See also

[25][26]

References

  1. ↑ Munger MA (Nov 2010). "Polypharmacy and combination therapy in the management of hypertens". Drugs Aging. 27: 871–83. doi:10.2165/11538650-000000000-00000. PMID 20964461.
  2. 1 2 "Polypharmacy in Elderly Patients" (PDF). Vumc.nl. Retrieved 16 January 2015.
  3. ↑ "polypharmacy". TheFreeDictionary.com. Retrieved 16 January 2015.
  4. ↑ Stawicki, S. P.; Gerlach, A. T. (2009). "Polypharmacy and medication errors: Stop, listen, look, and analyze...". OPUS 12 Scientist. 3 (1): 6–10.
  5. ↑ Haider, SI; Johnell, K; Thorslund, M; Fastbom, J (2007). "Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992 - 2002". International Journal of Clinical Pharmacology and Therapeutics. 45 (12): 643–653. doi:10.5414/cpp45643. PMID 18184532.
  6. ↑ Haider, SI; Ansari, Z; Vaughan, L; Matters, H; Emerson, E. (2014). "Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability". Research in Developmental Disabilities. 35 (11): 3070–3080. doi:10.1016/j.ridd.2014.07.060.
  7. ↑ da Cruz, Ligiane Paula; Miranda, Patrícia Monforte Miranda; Vedana, Kelly Graziani; Miasso, Adriana Inocenti (2011). "Medication therapy: Adherence, knowledge and difficulties of elderly people from bipolar disorder" (PDF). Revista Latino-Americana De Enfermagem (RLAE). 19 (4): 944–952. doi:10.1590/S0104-11692011000400013. PMID 21876947.
  8. ↑ Gellad, Walid F.; Grenard, Jerry L.; Marcum, Zachary A. (2011). "A systematic review of barriers to medication adherence in the elderly: Looking beyond cost and regimen complexity". American Journal of Geriatric Pharmacotherapy. 9 (1): 11–23. doi:10.1016/j.amjopharm.2011.02.004. PMC 3084587Freely accessible. PMID 21459305.
  9. ↑ Cline, C.M.J.; Björck-Linné, A.K.; Israelsson, B.Y.A.; Willenheimer, R.B.; Erhardt, L.R. (1999-06-01). "Non-compliance and knowledge of prescribed medication in elderly patients with heart failure". European Journal of Heart Failure. 1 (2): 145–149. doi:10.1016/S1388-9842(99)00014-8. ISSN 1879-0844.
  10. ↑ Yasein, Nada A.; Barghouti, Farihan F.; Irshaid, Yacoub M.; Suleiman, Ahmad A. (March 2013). "Discrepancies between elderly patient's self-reported and prescribed medications: a social investigation". Scandinavian Journal of Caring Sciences. 27 (1): 131–138. doi:10.1111/j.1471-6712.2012.01012.x. PMID 22616831.
  11. ↑ Haider, SI; Johnell, K; Weitoft, GR; Thorslund, M; Fastbom, J (2009). "The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people.". Journal of the American Geriatrics Society. 57 (1): 62–69. doi:10.1111/j.1532-5415.2008.02040.x. PMID 19054196.
  12. ↑ "When Is Polypharmacy an Advantage?". Ajp.psychiatryonline.org. Retrieved 16 January 2015.
  13. ↑ Sergi, G; De Rui, M; Sarti, S; Manzato, E (2011). "Polypharmacy in the elderly: Can comprehensive geriatric assessment reduce inappropriate medication use?". Drugs Aging. 28 (7): 509–518. doi:10.2165/11592010-000000000-00000.
  14. ↑ Mandell, A.J.; Selz, K.A. (1992). "Dynamical systems in psychiatry: Now what?". Biological Psychiatry. 32: 299–301. doi:10.1016/0006-3223(92)90034-w.
  15. ↑ Callahan, J.; Sashin, J. I. (1987). "Models of affect-response and anorexia nervosa". Ann. N.Y. Acad. Sci. 504: 241–259. doi:10.1111/j.1749-6632.1987.tb48736.x.
  16. ↑ Qato, DM; Wilder, J; Schumm, LP; Gillet, V; Alexander, GC (2016). "Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011". JAMA. 176 (4): 473–482. doi:10.1001/jamainternmed.2015.8581.
  17. ↑ Boyd, CM; Darer, J; Boult, C; Fried, LP; Boult, L; Wu, AW (2005). "Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance". JAMA. 294 (6): 716–24. doi:10.1001/jama.294.6.716. PMID 16091574.
  18. ↑ Haider, SI; Johnell, K; Thorslund, M; Fastbom, J (2007). "Analysis of the association between polypharmacy and socioeconomic position among elderly aged >/=77 years in Sweden". Clin Ther. 32 (2): 419–27. doi:10.1016/j.clinthera.2008.02.010. PMID 18343279.
  19. ↑ Page, AT; Clifford R., M; Potter, K; Schwartz, D; Etherton‐Beer, CD (14 April 2016). "The feasibility and the effect of deprescribing in older adults on mortality and health: A systematic review". British Journal of Clinical Pharmacology. doi:10.1111/bcp.12975. PMID 27077231.
  20. ↑ Potter, Kathleen; Flicker, Leon; Page, Amy; Etherton-Beer, Christopher (4 March 2016). "Deprescribing in frail older people: a randomised controlled trial.". PLoS One. 11 (3): e0149984. doi:10.1371/journal.pone.0149984. PMC 4778763Freely accessible. PMID 26942907.
  21. 1 2 Hilmer, Sarah N.; Gnjidic, Danijela; Le Couteur, David G. (December 2012). "Thinking through the medication list: appropriate prescribing and deprescribing in robust and frail older patients.". Australian Family Physician. 41 (12): 924–928. PMID 23210113.
  22. ↑ Cadogan, Cathal A.; Ryan, Cristín; Hughes, Carmel M. (2016). "Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many". Drug Safety. 39 (2): 109–16. doi:10.1007/s40264-015-0378-5. PMC 4735229Freely accessible. PMID 26692396.
  23. ↑ Sönnichsen, Andreas; Trampisch, Ulrike S.; Rieckert, Anja; Piccoliori, Giuliano; Vögele, Anna; Flamm, Maria; Johansson, Tim; Esmail, Aneez; Reeves, David; Löffler, Christin; Höck, Jennifer; Klaassen-Mielke, Renate; Trampisch, Hans Joachim; Kunnamo, Ilkka (29 January 2016). "Polypharmacy in Chronic Diseases – Reduction of Inappropriate Medication and Adverse Drug Events in Older Populations by Electronic Decision Support (PRIMA-eDS): Study Protocol for a Randomized Controlled Trial". Trials. 17 (57). doi:10.1186/s13063-016-1177-8. PMID 26822311. Retrieved July 15, 2016.
  24. ↑ Maher et. al. (2014). "Clinical Consequences of Polypharmacy in Elderly". Expert Opinion on Drug Safety. 13 (1): 57–65. doi:10.1517/14740338.2013.827660. PMC 3864987Freely accessible. PMID 24073682.
  25. ↑ Golchin, N (2015). "Polypharmacy in the elderly". Journal of research in pharmacy practice. 4: 85–8. doi:10.4103/2279-042X.155755. PMID 25984546.
  26. ↑ "Polypharmacy in the elderly.". J Res Pharm Pract. 4: 85–8. doi:10.4103/2279-042X.155755. PMID 25984546.

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