Polypharmacy
Polypharmacy (polypragmasia) is an
The prevalence of polypharmacy is estimated to be between 10% and 90% depending on the definition used, the age group studied, and the geographic location.
Polypharmacy is not necessarily ill-advised, but in many instances can lead to negative outcomes or poor treatment effectiveness, often being
Polypharmacy is often
Patient factors that influence the number of medications a patient is prescribed include a high number of chronic conditions requiring a complex drug regimen. Other systemic factors that impact the number of medications a patient is prescribed include a patient having multiple prescribers and multiple pharmacies that may not communicate.Whether or not the advantages of polypharmacy (over taking single medications or
Appropriate medical uses
While polypharmacy is typically regarded as undesirable, prescription of multiple medications can be appropriate and therapeutically beneficial in some circumstances.
Often certain medications can interact with others in a positive way specifically intended when prescribed together, to achieve a greater effect than any of the single agents alone. This is particularly prominent in the field of anesthesia and pain management – where atypical agents such as
Examples
- A legitimate treatment regimen in the first year after a
- In anesthesia (particularly IV anesthesia and hypnotics or analgesic inducing/maintenance agents such as midazolam or propofol, usually an opioid analgesic such as morphine or fentanyl, a paralytic such as vecuronium, and in inhaled general anesthesia generally a halogenated ether anesthetic such as sevoflurane or desflurane.[27]
Special populations
People who are at greatest risk for negative polypharmacy consequences include
It is not uncommon for people who are dependent or addicted to substances to enter or remain in a state of polypharmacy misuse.[32] About 84% of prescription drug misusers reported using multiple drugs.[32] 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. Reducing the number of medications, as part of a clinical review, can be an effective healthcare intervention.[33] 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 as adverse drug events, non-adherence, hospital admissions, drug-drug interactions, geriatric syndromes, and mortality.[34] 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. Staff at residential aged care facilities have a range of views and attitudes towards polypharmacy that, in some cases, may contribute to an increase in medication use.[35]
Risks of polypharmacy
The risk of polypharmacy increases with age, although there is some evidence that it may decrease slightly after age 90 years.[2] Poorer health is a strong predictor of polypharmacy at any age, although it is unclear whether the polypharmacy causes the poorer health or if polypharmacy is used because of the poorer health.[2] It appears possible that the risk factors for polypharmacy may be different for younger and middle-aged people compared to older people.[2]
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
Polypharmacy is associated with an increased risk of falls in elderly people.[39][40] Certain medications are well known to be associated with the risk of falls, including cardiovascular and psychoactive medications.[41][42] There is some evidence that the risk of falls increases cumulatively with the number of medications.[43][44] 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, some medications have interactions with other substances, including foods, other medications, and herbal supplements.[45] 15% of older adults are potentially at risk for a major drug-drug interaction.[46] Older adults are at a higher risk for a drug-drug interaction due to the increased number of medications prescribed and metabolic changes that occur with aging.[47] 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. For example, warfarin interacts with many medications and supplements that can cause it to lose its effect.[47][48]
Pill burden
Pill burden is the number of pills (tablets or capsules, the most common dosage forms) that a person 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. The use of individual medications is growing faster than pill burden.[49] A recent study found that older adults in long term care are taking an average of 14 to 15 tablets every day.[50]
Poor medical adherence is a common challenge among individuals who have increased pill burden and are subject to polypharmacy.
High pill burden was commonly associated with
Reducing pill burden is recognized as a way to improve medication
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.[medical citation needed] 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.[medical citation needed]
Interventions
The most common intervention to help people who are struggling with polypharmacy is deprescribing.[56] Deprescribing can be confused with medication simplification, which does not attempt to reduce the number of medicines but rather reduce the number of dose forms and administration times.[57] Deprescribing refers to reducing the number of medications that a person is prescribed and includes the identification and discontinuance of medications when the benefit no longer outweighs the harm.[58] In elderly patients, this can commonly be done as a patient becomes more frail and treatment focus needs to shift from preventative to palliative.[58] Deprescribing is feasible and effective in many settings including residential care, communities and hospitals.[56] This preventative measure should be considered for anyone who exhibits one of the following: (1) a new symptom or adverse event arises, (2) when the person develops an end-stage disease, (3) if the combination of drugs is risky, or (4) if stopping the drug does not alter the disease trajectory.[9]
Several tools exist to help physicians decide when to deprescribe and what medications can be added to a
Barriers faced by both physicians and people taking the medications have made it challenging to apply deprescribing strategies in practice.[64] For physicians, these include fear of consequences of deprescribing, the prescriber's own confidence in their skills and knowledge to deprescribe, reluctance to alter medications that are prescribed by specialists, the feasibility of deprescribing, lack of access to all of patients' clinical notes, and the complexity of having multiple providers.[64][65][66] For patients who are prescribed or require the medication, barriers include attitudes or beliefs about the medications, inability to communicate with physicians, fears and uncertainties surrounding deprescribing, and influence of physicians, family, and the media.[64] Barriers can include other health professionals or carers, such as in residential care, believing that the medicines are required.[67]
In people with multiple long-term conditions (multimorbidity) and polypharmacy deprescribing represents a complex challenge as clinical guidelines are usually developed for single conditions. In these cases tools and guidelines like the Beers Criteria and STOPP/START could be used safely by clinicians but not all patients might benefit from stopping their medication. There is a need for clarity about how much clinicians can do beyond the guidelines and the responsibility they need to take could help them prescribing and deprescribing for complex cases. Further factors that can help clinicians tailor their decisions to the individual are: access to detailed data on the people in their care (including their backgrounds and personal medical goals), discussing plans to stop a medicine already when it is first prescribed, and a good relationship that involves mutual trust and regular discussions on progress. Furthermore, longer appointments for prescribing and deprescribing would allow time explain the process of deprescribing, explore related concerns, and support making the right decisions.[68][69]
The effectiveness of specific interventions to improve the appropriate use of polypharmacy such as pharmaceutical care and computerised decision support is unclear.[9] This is due to low quality of current evidence surrounding these interventions.[9] High quality evidence is needed to make any conclusions about the effects of such interventions in any environment, including in care homes.[70] Deprescribing is not influenced by whether medicines are prescribed through a paper-based or an electronic system.[71] Deprescribing rounds has been proposed as a potentially successful methodology in reducing polypharmacy.[72] Sharing of positive outcomes from physicians who have implemented deprescribing, increased communication between all practitioners involved in patient care, higher compensation for time spent deprescribing, and clear deprescribing guidelines can help enable the practice of deprescribing.[66] Despite the difficulties, a recent blinded study of deprescribing reported that participants used an average of two fewer medicines each after 12 months showing again that deprescribing is feasible.[73]
See also
- Adverse effect
- Classification of Pharmaco-Therapeutic Referrals
- Compliance
- Deprescribing
- Multimorbidity
References
- ^ PMID 29017448.
- ^ PMID 35814333.
- PMID 32103967.
- PMID 28603638.
- S2CID 243406561.
- PMID 34168565.
- ^ "polypharmacy". Oxford English Dictionary. 2022.
The use of multiple drugs or medicines for several concurrent disorders (now esp. by elderly patients), often with the suggestion of indiscriminate, unscientific, or excessive prescription.
- ^ "A Glossary of Terms for Community Health Care and Services for Older Persons" (PDF). World Health Organization. 2004. p. 45. Retrieved September 6, 2022.
1 The administration of many drugs at the same time. 2 The administration of an excessive number of drugs.
- ^ PMID 37818791.
- PMID 32587680.
- PMID 21876947.
- PMID 21459305.
- PMID 31219179.
- S2CID 32043403.
- PMID 22616831.
- PMID 25129201.
- PMID 26529160.
- PMID 29036509.
- S2CID 205703844.
- PMID 28140305.
- ^ S2CID 225671789.
- ^ "Polypharmacy in Elderly Patients" (PDF). Vumc.nl. Archived from the original (PDF) on 22 January 2016. Retrieved 16 January 2015.
- PMID 21724668.
- ^ )
- PMID 22737266.
- S2CID 28551158.
- PMID 21386084.
- PMID 35282537.
- S2CID 28090181.
- PMID 18343279.
- S2CID 186205805.
- ^ a b Omenka I, Greene MS (2017-08-01). Polypharmacy Among Prescription Drug Users. Indiana University Center for Bioethics, Indiana State Department of Health, The Association of State and Territorial Health Officials (ASTHO) (Report).
- PMID 27077231.
- PMID 18179993.
- S2CID 235630612.
- ^ S2CID 253363170.
- PMID 34097766.
- ISSN 1525-8610.
- )
- OCLC 1031268452.
- S2CID 44942.
- PMID 29396189.
- S2CID 23910834.
- PMID 25516023.
- ^ "Drug Interactions: What You Should Know". Center for Drug Evaluation and Research. U.S. Food and Drug Administration. 2020-03-17.
- PMID 26998708.
- ^ S2CID 6621392.
- S2CID 205825132.
- PMID 31219179.
- S2CID 253363170.
- ^ PMID 32098393.
- S2CID 209445305.
- PMID 24267603.
- PMID 24073682.
- ^ PMID 23210113.
- ^ PMID 27077231.
- PMID 31326924.
- ^ PMID 26692396.
- S2CID 258486318.)
{{cite journal}}
: CS1 maint: numeric names: authors list (link - S2CID 208611400.
- ^ "STOPP-START - CGA Toolkit Plus". cgakit. Retrieved 2023-05-06.
- ^ "MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia".
- PMID 27527376.
- ^ PMID 28063660.
- PMID 25488097.
- ^ PMID 27093289.
- S2CID 235630612.
- S2CID 258801327.
- PMID 35894932.
- PMID 26866421.
- S2CID 227167464.
- S2CID 53730423.
- S2CID 254917543.
Further reading
- Golchin N, Frank SH, Vince A, Isham L, Meropol SB (April 2015). "Polypharmacy in the elderly". Journal of Research in Pharmacy Practice. 4 (2): 85–88. PMID 25984546.
- Morrison L, Duryea PB, Moore C, Nathanson-Shinn A, Hall SE, Rose E. Psychiatric Polypharmacy: A Word of Caution. PsychRights.org (Report). Protection & Advocacy, Inc.
External links
- "Position Statement on Polypharmacy and the Older Adult". Council on Gerontological Nursing, Congress of Nursing Practice. American Nurses Association. 15 December 1990. Archived from the original on 2001-04-17.
- "Technical Report on Psychiatric Polypharmacy" (PDF). National Association of State Mental Health Program Directors. 9 October 2001. Archived from the original (PDF) on 2005-03-20.
- "Polypharmacy in Older Adults: Information for people who are taking several medications". School of Medicine. University of North Carolina at Chapel Hill. Archived from the original on 2008-12-02.
- "Appropriate Prescribing for Patients and Polypharmacy Guidance for Review of Quality, Safe and Effective Use of Long-term Medication" (PDF). Scotland NHS. 2012. Archived from the original (PDF) on 2013-01-24.