THE PITFALLS OF POLYPHARMACY AND HOW TO AVOID THEM

At what point does treatment overcompensate and start to contribute negatively toward a health condition? Polypharmacy could either be the main culprit behind one’s symptoms or a requirement for maintaining optimal well-being.

The below discussion endeavors to explain what polypharmacy is and what one can do to minimize the risks associated with it.

What is Polypharmacy? Definitions and Importance

Polypharmacy is the use of multiple medications in the treatment and management of disease.

There is no clear-cut definition that has been decided upon for what constitutes polypharmacy, although it is usually quoted as making use of 5 or more pharmaceutical medications per day. Inappropriate polypharmacy may consist of taking anywhere between 2 and 11 medications daily.

Definitions of polypharmacy are generally limited to set pharmaceutical prescriptions acquired at the doctor’s office. However, over-the-counter drugs, non-essential supplements, and complementary medications should also be taken into consideration due to their biological effects.

Polypharmacy is a Silent Pandemic

Polypharmacy is beginning to be considered a silent pandemic due to its common occurrence, especially in older adults and those with multiple health conditions. Across a wide range of studies, the prevalence of polypharmacy can range anywhere between 10-90% depending on the population^[1]. Average global estimates suggest that polypharmacy is present in 10-20% of the overall population, of which 40-60% consist of the elderly.^[2]

The WHO has created a global initiative, ‘Medication Without Harm’ regarding the safety of prescribing medications with the aim of minimizing polypharmacy, transitions of care, and high-risk situations. Healthcare practitioners are urged to take an individualized approach to therapy that enhances the benefit and reduces potential harm.^[3]

Appropriate vs. Inappropriate Polypharmacy

Polypharmacy may be either beneficial or harmful, depending on the context. Guidelines for appropriate and inappropriate polypharmacy have been suggested by the WHO in accordance with their initiative.

Appropriate Polypharmacy results when all medications are required for treatment and ought to meet the following criteria:

• Medications have been prescribed with specific therapeutic aims that have been agreed upon between patient and practitioner.
• The therapeutic aims of the prescription are either being met or stand a high chance of being met through the course of treatment.
• The doctor has optimized the prescription in a way that minimizes adverse drug reactions.
• The patient is willing and able to take all prescribed medications.

Inappropriate polypharmacy occurs when one or more medications are no longer required, as indicated by:

• Symptom absence, resolution, or reduction, resulting in medication overdose.
• One or more prescription drugs fail to achieve therapeutic aims.
• Medications result in adverse drug reactions or greatly increase the risk for them.
• The patient is unwilling or unable to take one or more of the prescribed medications.

The Dangers of Inappropriate Polypharmacy

Inappropriate polypharmacy is often a risk factor for symptom exacerbation and many adverse effects.

Some of the most prevalent adverse events that result from polypharmacy include^[4]:

• Increased hospitalization risk
• Falls and fractures
• Weight loss
• Cognitive impairment
• Urinary incontinence
• Elevated risk for palliative care or nursing home placement in elderly individuals
• Lower life quality
• The incurrence of extra symptoms due to interactions between different drugs, their side effects, and their effects on comorbid conditions they were not intended to treat

Risk Factors for Inappropriate Medication Use

The following factors are associated with the increased prevalence of polypharmacy:

• Age. Polypharmacy and potentially inappropriate medication use increase with age, even between elderly cohorts.^[5] Despite this prevalence in the elderly, medication effects are typically stronger in this cohort which should lend itself to more deprescription. Furthermore, disease indications typically differ between younger and older individuals due to metabolism. Thus, certain prescriptions may be replaced with different medications or dosages as one ages. When prescribing for the elderly, life expectancy, quality of life, and the aims of the patient and/or carers need to be taken into consideration.
• Multiple Doctors. In a large study on approximately 8000 elderly Japanese individuals, it was found that just under 23% of patients had been to two or more doctors. Each time a patient visits a different doctor, they are 5-6 times more likely to be prescribed a new medication which gives rise to polypharmacy.^[6]
• Multimorbidity usually goes hand-in-hand with polypharmacy and refers to two or more long-term comorbid health conditions being present in the same individual. Each condition typically requires additional prescription medications for symptom management and treatment. Trends of multimorbidity have been identified across populations and are likely to reflect genetic factors.^[7]
• Disease Complexity. Some diseases have symptoms that create an overlap between multiple body systems, requiring multiple medications for an array of symptoms.
• Transient Illness, Allergy, or Injury. Infections, seasonal allergies, or injuries can contribute to the risk for polypharmacy by increasing the need for additional medications such as painkillers, antihistamines, and antibiotics.

Tips to Avoid the Pitfalls of Polypharmacy

The below tips can help to minimize the risk of polypharmacy, highlighting the importance of patient and doctor collaboration.

Less Doctoring is More. To minimize polypharmacy, let one healthcare provider manage all your prescriptions and avoid collecting multiple prescriptions from different doctors. Some healthcare providers have the added advantage of belonging to a network that allows for large-scale integration of medical expertise across several specialists. For multiple doctoring to work in favor of the patient, communication amongst physicians needs to be optimal, and the patient needs to discuss their prescriptions with each practitioner.

Discuss Your Prescription List. As a patient, it is not possible to know all the factors affecting a prescription, and as a doctor, it is not always possible to allocate time toward reducing unnecessary prescriptions in a patient’s medication list. Inquiring and discussing the current prescription list in line with the current symptom set to be sure they are not taking any unnecessary medications can be helpful for the patients. This advice is especially pertinent for patients required to take more than 5 medications or for those who experience a drastic change in symptoms. It may help to ask if there are any medications that fall into the same class of drugs, as this is a common scenario that often leads to inappropriate polypharmacy. NSAIDs and benzodiazepines are two of the most common classes of drugs that are frequently duplicated in a prescription list. However, there are many more.

Mention Non-Prescribed Medications. You ought to let your doctor know about any new non-essential supplements you may be taking or over-the-counter drugs that are not included in your prescription list. The doctor may be able to recommend something better that does not coincide with your current treatment plan. If you are considering a potent food grade or natural supplement that falls outside of your doctor’s realm of expertise, be sure to check with a nutritionist or similar specialist who has the expertise to research your case.

New Script Confirmation. It is important that you get written confirmation or, even better, a new prescription if your doctor makes a change to the prescription list. This can help to reduce prescription errors between practitioner, patient, and pharmacist, particularly in the case of an individual with multiple comorbidities who takes many medications. This aids in keeping track of the patient’s medical history, as it clearly shows the dosages of each medication, when medications were stopped or started, as well as what medications were taken together or not during long-term treatment.

Take Note of Symptom Changes. If symptoms change drastically or new symptoms arise when beginning or stopping a new medication, it is important to take note and schedule another appointment to re-address one’s prescriptions.

Conclusion

Polypharmacy may be either beneficial or dangerous, depending on the circumstance. It typically affects older individuals more often than younger populations. The pitfalls of polypharmacy pertain to the increased risk of incurring adverse effects at the extra expense of the patient. Healthcare physicians ought to monitor a patient’s prescription list and remove any potentially inappropriate medications during follow-up appointments. Patients should be aware of polypharmacy risks and pay extra attention to prescription updates and resultant symptom changes.

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