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Polypharmacy

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Polypharmacy, Judicious Prescribing

  • Definitions
  1. Polypharmacy
    1. Too many medications or use of unnecessary drugs
    2. Five or more medications used empirically
  • Epidemiology
  1. Patients over age 65 years consume one third of all medications in the United States
    1. Average patient uses 4 perscribed medications and at least one OTC medication
  • Risk Factors
  1. Older adults (over age 62 years old)
  2. Multiple specialist providers, but no primary medical provider
  3. Long-term care facility residents (91% are on 5 or more medications daily)
  4. Younger patients with complex health conditions
    1. Developmental Delay
    2. Cognitive Impairment
    3. Chronic Pain
    4. Diabetes Mellitus
    5. Heart Disease
    6. Cerebrovascular Disease
    7. Mental Health Conditions
    8. Cancer
  • Precautions
  1. Polypharmacy leads to increased adverse drug events (ADEs) including Drug Interactions
    1. See Drug-Drug Interactions in the Elderly
    2. See Medications to Avoid in Older Adults
    3. See Medication Causes of Delirium in the Elderly
    4. Patients on 2 drugs have a 35% risk of ADE, while those on >6 drugs have an 82% ADE risk
      1. Klein (1984) Arch Intern Med 144(6): 1185-88 [PubMed]
      2. Gallagher (2007) J Clin Pharm Ther 32(2): 113-21 [PubMed]
    5. Adverse drug events are among the top 6 U.S. causes of death (esp. in the elderly)
    6. Adverse drug events contribute to 10-20% of hospitalizations
    7. Most common adverse drug events are due to a shorter list of medications
      1. Oral Anticoagulants (esp. Warfarin) and antiplatelet drugs
      2. Insulin and other diabetic medications
      3. Digoxin
      4. Cardiovascular drugs
      5. Psychotropic drugs
  2. Avoid stopping Statins if tolerated and more than 1 year Life Expectancy
    1. Continue to lower cardiovascular risk at any age
  • Prevention
  • Decreasing Polypharmacy
  1. Try to use "one drug per disease once daily"
  2. Stop drugs without proven benefit or indication
    1. See Deprescribing
  3. Consider withdrawing antihypertensives in elderly
    1. Especially in those with low pressure on therapy
    2. Up to one third of patients remain normotensive
      1. If BP increases, it usually does in first 70 days
    3. References
      1. Nelson (2002) BMJ 325:815-7 [PubMed]
  4. When starting medications, practice Judicious Prescribing
    1. First consider nonpharmacologic management
    2. Start low and go slow when adding a new medication
    3. Use least toxic medications with the widest therapeutic window
    4. Avoid treating iatrogenic side effect with another drug
    5. Avoid treating every symptom
    6. Avoid duplicate drugs from the same medication class
    7. Avoid starting more than one new medication at the same time
    8. Consider each new medication start as a trial
      1. Set re-evaluation date 2-4 weeks after starting a medication and discontinue if fails to offer benefit
  5. Review medications at every visit
    1. Avoid increasing dose until fully verifying compliance with currently prescribed dose
      1. Drugs will not be consistently effective if not consistently taken
      2. At least 25-50% of elderly do not take medications as directed (due to adverse effects, cost)
      3. Medication errors are common due to decreased vision and consolidating medication bottles
    2. Accurately record drugs and their dosing and schedule at every visit (medication reconciliation)
      1. Poor medical record keeping are a significant risk for Polypharmacy complications
      2. Patient should bring all medications to each visit
      3. Includes all prescribed, OTC, Herbals and supplements
      4. List all drugs by generic name and class
    3. Review adverse effects of prescribed medications
      1. Decrease, switch or stop antihypertensive agents for Orthostasis, Dizziness, Hypotension or Bradycardia
      2. Relax management goals (e.g. Hemoglobin A1C) in the elderly, especially if Hypoglycemia occurs
    4. Review medications at Transitions of Care (e.g. post-hospitalization)
      1. See Transitions of Care
    5. Re-evaluate medications started at a younger age that have never been adjusted
      1. Adjust for decreasing Renal Function and hepatic function
        1. Metformin and Sulfonylureas may require discontinuation for Renal Insufficiency
      2. Agents without proven efficacy may be discontinued
        1. Niacin and Zetia appear to add little to the prevention of cardiovascular events
      3. Agents started at a younger age may be contraindicated in older patients
        1. See Medications to Avoid in Older Adults (STOPP, Beers' Criteria)
        2. Stop Anticholinergic Medications
      4. Agents may have failed to improve quality of life or functional status
        1. Dementia medications (e.g. Aricept, Namenda) may offer no added benefit
        2. When Life Expectancy is limited, consider stopping Bisphosphonates, diabetes medications
      5. Agents used for prophylaxis for a medication that has been discontinued
        1. Proton Pump Inhibitor while on NSAID
  6. Every visit is an opportunity to STOP a medication
    1. See Deprescribing
    2. Trial off one medication at a time
    3. If not able to stop a medication, consider lower doses
    4. Re-evaluate weeks after stopping a medication
      1. What symptoms were improved, unchanged, worsened?
      2. What clinical markers changed (eg. Blood Pressure)?
      3. Is there a reason to restart or replace this drug?
  7. Practice guidelines ("Quality" Measures) and Pay for Performance (PFP) drive Polypharmacy
    1. Interpret Pay for Performance and quality guidelines in context of patient
      1. May be inappropriate for extreme elderly
      2. May decrease quality of life in end-stage disease
      3. Drug benefits often delayed beyond Life Expectancy
    2. Where are they on the cure vs Palliative Care spectrum?
      1. Primary prevention is not focus in Palliative Care
      2. Shift end stage care to focus on palliation
        1. Prevent decline by treating acute disease
        2. Focus on symptom management for comfort
  • Protocol
  • Evaluate each drug for risk versus benefit
  1. Is the medication indicated with efficacy?
  2. Is dosage and directions appropriate and practical?
  3. Are there significant drug or disease interactions?
  4. Have there been significant adverse effects (e.g. increased fall risk)?
  5. Is the duration of therapy appropriate?
  6. Is there unnecessary duplication with other drugs
  7. Is this the most cost-effective drug option?
  8. References
    1. Samea (1994) J Clin Epidemiol 47:891-6 [PubMed]
  • Protocol
  • Indications to reevaluate medication list
  1. Every routine visit
  2. Following hospital of Nursing Home discharge
    1. Medications may have been added or adjusted for acute event
    2. Consider decreasing dose or discontinuing medication completely at follow-up
  3. Acute events
    1. Falls or Orthostatic Hypotension
    2. Heart Failure
    3. Delirium