This course discusses the definitions associated with various polypharmacy categories as well as the debate around polypharmacy in patient care.
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Upon completion of this course, the course participant will be able to:
- What is polypharmacy?
- Polypharmacy: Good or Bad
- Disadvantages of Polypharmacy
Polypharmacy refers to concurrent use of multiple drugs by a patient. When a patient is prescribed multiple medications, the risk of adverse effects and drug interactions increases, especially in the elderly people. Inappropriate polypharmacy is associated with serious problem resulting in significant morbidity and mortality. Additionally, polypharmacy increases the cost. It is a challenge to keep balance between benefits and adverse effects while using multiple drugs. This chapter will cover all about polypharmacy including its background, its impact on the national cost, benefits and drawbacks.
WHAT IS POLYPHARMACY?
Polypharmacy refers to the concurrent use of multiple drugs by a patient. Poly means “many” and “pharmacy” means “practice of medicinal drugs” which refers to the use of many drugs at a time. However, use of this term in inconsistent in the medical literature as it refers to different meanings at different places. For example, it refers to negative and inappropriate use of medication while in others it reflects appropriate combination of multiple drugs for the treatment of a disease or condition. Hence, polypharmacy can be positive as well as negative. Bushardt et al. (2008) review eleven articles on polypharmacy and found 24 different definitions. The most common definition they found was related to “medication does not meet the diagnosis”. Therefore, they suggested that this term should be avoided in the literature until there is no clear definition is established. Most commonly, polypharmacy is encountered in the elderly people who suffer from multiple illnesses.
Figure 1: Polypharmacy among the elderly (Source: www.mja.com.au)
Definitions of Polypharmacy:
World Health Organization: The administration of many drugs at the same time or the administration of an excessive number of drugs”.
Minor Polypharmacy: The use of 2-4 drugs.
Major Polypharmacy: The use of ≥5 drugs.
Hyperpolypharmacy: The use of ≥10 drugs.
Same Class Polypharmacy: The use of > 1 drug of same class.
Multi-class Polypharmacy: The use of > 1 drug from different classes of drugs.
Adjuvant Polypharmacy: The use of actual drugs plus another drug to reduce the side effects of actual drug.
Figure 2: Types of polypharmacy (Source: www.slideshare.net)
The synonyms of polypharmacy may include polymedication, multimedication, polyprescription or multiprescription.
POLYPHARMACY: GOOD OR BAD?
Polypharmacy is still to be debated. It may be good or bad as it depends upon the particular combination of diagnosis and medications in the given case. For example, if a patient is given multiple drugs which can interact adversely with each other, it may harm the patient. On the other, if a patient with right diagnosis is offered with multiple drugs of right combination, it will be beneficial for the patient. For instance, in a patient with myocardial infarction, a combination of drugs is given i.e. statin, beta-blocker, angiotensin converting enzyme inhibitors, aspirin and antidepressant. Similarly, a patient with heart failure also requires multiple drugs. In this way, the patient gets benefit from the multiple drugs. Hence, use of multiple drugs does not reflect poor treatment or overmedication. The elderly people are at risk of multiple conditions requiring combination of drugs. Therefore, it would be better to say that polypharmacy is bad when inappropriate combination of drugs is used by the patient while it is good when accurate combination is used with respect to the particular diagnosis.
Figure 3: Good or bad? (Source: www.thecorporatecaterer.com)
What factors contribute to Polypharmacy?
Use of drugs without any evidence based indication, or there is no more indication
The drug failed to achieve the therapeutic objectives
The drugs causing adverse effects
All the drugs being used to achieve specific therapeutic outcomes
Therapeutic objectives are being achieved
Optimized use of drugs
The patient is counseled and is motivated to comply with the treatment.
Figure 4: Appropriate and inappropriate (Source: www.infiniteach.com)
DISADVANTAGEOUS EFFECTS OF POLYPHARMACY
Unfortunately, polypharmacy results in various negative consequences, afceting the quality of life. Most importantly, increased costs and treatment non-adherence are the major drawbacks. According to an estimate, 25-40% people above 65 years are prescribed more than 5 drugs. This increased number of drugs in old age poses a lot of risks as physiological functions decline in the elderly. Disadvantages of polypharmacy include the following (Maher et al. 2014):
Increased health care costs
Adverse drug reactions
Poor quality of life
Figure 5: Disadvantages of Polypharmacy
Increased health care costs: Inappropriate polypharmacy increases healthcare costs and pill burden. According to an estimate, polypharmacy adds up to 30% in medical costs along with increased outpatients visits and hospital admissions (Akazawa et al. 2010). Hence, avoiding inappropriate polypharmacy will reduce the healthcare costs.
Adverse drug reactions: Drug side effects are a major contribution to hospital visits. According to an estimate 35% and 40% outpatients and hospitalized patients experience drug side effects, respectively (Hohl et al. 2001). A lot of studies have reported that the patients taking more than 9 medicines experience twice adverse side events (ADEs) as compared to those who take less number of drugs. Sometimes, drugs cause life-threatening ADEs.
Figure 6: Adverse drug events (Source: www.google.com)
Drug-drug interactions: Drug-drug interactions are also a major problem when a patient takes multiple drugs. According to a study, up to 80% patients experienced drug-drug interactions who were taking 5 or more than 5 drugs (Maher et al. 2014). Risk of drug-drug interactions increases as the number of drugs increases.
Drug non-adherence: Polypharmacy results in drug non-adherence as it becomes difficult for a patient to take a large number of pills on daily basis. In the elderly patients, drug non-adherence has been observed between 43-100% of the patients. Drug non-adherence is associated with potential disease progression, treatment failure, increased hospital admissions and ADEs.
Poor quality of life: Polypharmacy leads to functional decline and cognitive impairment. Studies have reported reduced ability to perform instrumental activities of daily living (IADLs) among the patient who take 5 or more drugs (Crenstil et al. 2010).
William Osler said, “One of the first duties of the physician is to educate the masses not to take (inappropriate) medicine”. Most of the time, polypharmacy favours the inappropriate use of medicines or to use the medication that does not meet the diagnosis. However, justified combination of multiple drugs with respect to the particular diagnosis benefits the patient. On the basis of inconsistent use of the term “polypharmacy” needs to be fixed.
If polypharmacy is taken in a positive sense, especially in the patients with heart diseases, it may be justified. However, there are certain disadvantages of polypharmacy including increased healthcare costs, side effects, drug-drug interactions, non-adherence and poor quality of life.
Akazawa, M., Imai, H., Igarashi, A., Tsutani, K. (2010). Potentially inappropriate medication use in elderly Japanese patients. The American Journal of Geriatric Pharmacotherapy, 8, 146–160.
Bushardt, R.L., Massey, E.B., Simpson, T.W., Ariail, J.C., et al. (2008). Polypharmacy: Misleading, but manageable. Clinical Interventions in Aging, 3(2), 383-389.
Crenstil, V., Ricks, M.O., Xue, Q.L., Fried, L.P. (2010). A pharmacoepidemiologic study of community-dwelling, disabled older women: factors associated with medication use. The American Journal of Geriatric Pharmacotherapy, 8, 215–224.
Hohl, C.M., Dankoff, J., Colacone, A. and Afilalo, M. (2001). Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Annals of Emergency Medicine, 38, 666–671.
Maher, R.L., Hanlon, J.T. and Hajjar, E.R. (2014). Clinical Consequences of Polypharmacy in Elderly. Expert Opinion on Drug Safety, 13(1), 57-65.
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