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Sameen et al. World Journal of Pharmacy and Pharmaceutical Sciences
www.wjpps.com Vol 7, Issue 10, 2018.
384
POLYPHARMACY: AN OVERVIEW
Sameen*, Ankita Kumar and Rahul Saini
Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR) Pushpvihar Sector 3,
New Delhi – 110017, India.
ABSTRACT
Polypharmacy is associated with the combination of too many
medicines in one prescription for the patient which leads to high risk of
drug-drug interactions and adverse drug reactions. The main goal of
this review study is to provide an overview using observational studies.
It aims to inspect the epidemiology of polypharmacy and to review
various types of studies which have been published in the past two
decades targeted to manage polypharmacy. Cohort studies, systemic
reviews, clinical trials and meta-analysis were used to examine and
analyze several consequences of polypharmacy and its management.
Physicians and clinical pharmacists plays a key role in management of
polypharmacy through a range of interventions such as by reducing the
number of medications taken, doses to be taken, preventing adverse
drug reactions (ADRs), improving patient‘s quality of life, increasing patient adherence with
the medication and decreasing competence and drugs cost. Nowadays, various types of tools
and technologies are available in managing polypharmacy such as the use of clinical decision
support system, artificial intelligence,use of smart phone applications, medical reconciliation
and by optimizing the use of medicines.
KEYWORDS: Polypharmacy, Multi-morbidity, De-prescribing, Medicine Reconciliation,
Smart phone applications
INTRODUCTION
Polypharmacy term comes from Greek root phrases; ‗poly‘, that means many, and
‗pharmakeia‘ which means drug. It is commonly used when one person is taking too many
medicines, or the medicine has been prescribed through many doctors with improper
coordination. The definition of polypharmacy continues to be arguable.[1,2]
Generally,
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
SJIF Impact Factor 7.421
Volume 7, Issue 10, 384-410 Review Article ISSN 2278 – 4357
Article Received on
24 July 2018,
Revised on 13 August 2018,
Accepted on 02 Sept. 2018
DOI: 10.20959/wjpps201810-12320
*Corresponding Author
Sameen
Pharmacology Department,
Delhi Institute of
Pharmaceutical Sciences
and Research (DIPSAR)
Pushpvihar Sector 3, New
Delhi -110017, India.
Sameen et al. World Journal of Pharmacy and Pharmaceutical Sciences
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385
polypharmacy is defined as the concurrent use of more than one medication by a person. The
particular quantity of medicines administered is not itself indicative of polypharmacy as all of
the medicines can be clinically important and suitable for the affected person. However,
because the wide variety of prescription drugs will increase, so does the possibility of
polypharmacy.[3]
It includes taking a multitude of medicines which can be prescribed
medicines, over the counter (OTC) drugs, complementary medicines or some dietary
supplements. This can cause not only harm to the patient but can be dangerous too.[4]
Polypharmacy is maximum observed in the aged, affecting approximately 40% of older
adults residing in their own homes and approximately 21% of adults with cerebral infirmity
are also viable for polypharmacy.
Polypharmacy has not always been, but occasionally bad and frequently being greater
detrimental than beneficial or presenting too much risk for too little benefit. Fitness experts
bear it in mind as a situation that requires monitoring and overview to validate whether or not
all the medicines are essential to it, whether it includes elevated or destructive drug reactions,
drug interactions, prescribing cascade, and costs.[5]
It is generally related to a reduced first-
rate of lifestyles, along with decreased mobility and cognition. Polypharmacy is just an area
presenting more difficulties to elderly due to numerous reasons. Elderly people are at greater
risk for unfavorable ADRs owing to the decreased clearance associated with old age;
furthermore, exacerbated with the aim of increasing the quantity of drug used.[6]
Polypharmacy may occasionally lead to ―prescribing cascades‖ in which ―signs and
symptoms‖ (more than one and nonspecific) of an ADR is misinterpreted as a disease and a
new treatment or drug therapy is further delivered in addition to the earlier prescribed
treatment. This inherits the potential to expand in addition to more facet-results and
consequently creating a prescribing cascade. Assessment of polypharmacy is of vital issue in
an aged patient so that it will avoid all of the viable unfavorable effects. Complete medicine
review and danger assessment have to be executed by means of interdisciplinary crew to
identify the polypharmacy and its unfavorable consequences.
Polypharmacy can be manageable; it requires great knowledge of the physician, non-medical
staff patient and support from government and health care institution. It can be managed
through number of ways such as-by using risk prediction tool, optimizing the use of
medicine, using different tools and technologies such as artificial intelligence and cognitive
computing, using medicine reconciliation process and through use of computerized clinical
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decision-making system and various type of smart applications along with further research to
validate some processes.[7]
More tools and processes should be developed to reduce the
incidence of polypharmacy and the risk which are associated with it.
REASONS FOR POLYPHARMACY
1. As the population ages, polypharmacy will increase. The elderly requires frequent multiple
medications to cope up with manifold fitness-associated situations.[8]
2. The patient with a couple of comorbid scientific situations requires numerous medications
to treat every situation. It is not unreasonable for an affected person with more than one
comorbid clinical conditions to be on 6 or 9 medicinal drugs to reduce his/ her long-term
danger for those conditions, e.g., diabetes situations and coronary activities.
3. Sudden withdrawal and restarting of the drug increases the duration of patient stay in the
hospital thus patient becomes vulnerable to polypharmacy.
4. More than one medical doctor is prescribing medicines for the same subject. Once a patient
starts a remedy, it's miles in no way discontinued.
5. Lack of patient education is also a cause of polypharmacy as the doctor does not inform
and patient do not ask the question about ADRs and contraindications to them.[9]
CONSEQUENCES OF POLYPHARMACY
EXPANDED HEALTHCARE COST
Polypharmacy adds to fitness care expenses to both the affected person and the healthcare
system. A retrospective cohort study found that polypharmacy was associated with
accelerated risk of taking inappropriate drugs and enhanced the risk of outpatient visits, and
hospitalization with an approximate 30% increase in medical fees.[10]
A study conducted in
Sweden suggested that the patient taking 5 or greater medicines had a 6.2% increase in
prescription drug expenditure and those taking 10 or extra medicinal drugs had a 7.3%
increase.[11]
ADVERSE DRUG REACTION
In 2005, it was estimated that over 4.3 million fitness care visits had been assigned to an
adverse drug event (ADE).[12]
It had been manifested that up to 35% of outpatients and 40%
of hospitalized elderly were encountered with an ADR. Moreover about 10% of emergency
room visits were also attributed to an ADE. In a study built on population, outpatients taking
5 or more medications had an 88% improved risk of experiencing an ADE compared to
people who were taking fewer medications.[13]
In nursing domestic citizens, rates of ADRs
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had been noted to be twice as high in patients taking 9 or greater medicinal drugs compared
to those taking less (Table 1).
Table 1: Common drug classes related to ADEs.[14, 15]
Anti-coagulants
Nonsteroidal anti-inflammatory
drugs (NSAIDS)
Cardiovascular
Diuretics
Antibiotics
Anti- convulsant
Benzodiazepines
Hypoglycemics
DRUG INTERACTION
According to a prospective cohort study of older hospitalized adults which are taking 5 or
more medications, the incidence of drug-drug interaction due to a potential hepatic
cytochrome enzyme-mediated was found to be 80%. The probability increased with an
increase no of medicines, if the patient is taking 5-9 medications, have probability around
50%, whereas 100% when the patient takes 20 or more medication.[16]
Depending on a study
of community-dwelling elderly adults, a potential drug-drug interaction was noted in almost
50% of patients. These interactions are frequent cause of the ADEs and medication-related
hospitalization. So, it‘s the duty of the practitioner to keep this factor in mind while
prescribing new medication.[17]
According to studies, prevalence of the drug- disease interaction was found to be 15-40% in
fairly elderly patient. Risk built up on increasing the number of medications. The patient with
chronic disease is at higher risk, so it is the duty of the healthcare provider to minimize this
interaction while prescribing.[18]
FUNCTIONAL STATUS
Polypharmacy is linked to the functional decline in the elderly patient. Depending on a
prospective study of community-dwelling adults, increased medication use was linked with
diminished ability to accomplish instrumental activities of daily living (IADLs) and also
reduced the physical functioning. According to the study which used data from a Women‘s
Health and Aging Study, concluded that the use of 5 or more medicine was associated with a
decreased ability to perform IADLs.[19]
According to the prospective cohort study of
approximately 300 elderly patients it was found that patients taking 10 or more medication
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had a detrimental effect on functioning capacity and performing of quotidian routine task.
According to the Observational study of Women's Health Initiative, it was found that
polypharmacy was accompanying with incident disability in the older women. Prescribers
should be attentive of the risk of functional decline associated with patients taking multiple
medications.[20]
COGNITIVE IMPAIRMENT
Cognitive impairment, perceived with both delirium and dementia, has been linked with
polypharmacy. According to a study in hospitalized older adults it was reported that the
number of prescribed medicines was a risk factor for delirium.[21]
According to prospective
cohort study of approximately 294 elder patients it was noted that 22% percent of the patients
taking 5 or fewer medications had associated with impaired cognition as opposed to 33% of
patients taking 6-9 drugs and 54% in patients taking 10 or more drugs.[20]
FALLS
According to the study of older adult outpatients it was found that increase in the no of
medication, increased the risk of falling index score and decreased the duration of one leg
standing test. In a prospective cohort study, it was found that the use of 4 or more
medications was linked with the increased risk of falling and the risk of recurring falls.[22]
According to the study in older patients with dementia it was found that the patient who had
reported a fall had an increased prevalence of the polypharmacy.[23]
IDENTIFYING PATIENTS WITH POLYPHARMACY
Duerden and Avery, in their report to the King's Fund, layout a realistic way to deal with
distinguishing patients with polypharmacy and identify 'in danger' patients utilizing a
combination of both patient characteristics and not of prescribed medicine. This approach
depends on earlier research demonstrating a relationship between the adverse outcome of
health and polypharmacy, and that this affiliation is more set apart in patients with major
disease. Duerden and Avery suggested concentrating on patients who are on at least 10
medications; or patients getting 5-9 drugs who have other hazard factors. For example, a
significant comorbidity (e.g. rheumatoid joint inflammation or diabetes, have been reported
to suffer from adverse drug reaction are from vulnerable group [people with a learning
disability or living in care homes). Another study from the UK reported that three commonest
drugs are associated with the adverse drug reaction which resulted in-hospital admission was
non-steroidal anti-inflammatory agents, warfarin and diuretics.[24]
These types of studies can
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guide the physician to recognize the patient who may be at highest risk from complications
related to the polypharmacy.
The fast advancement, execution and utilization of electronic patient records in primary
health care help to simplify the process of recognizing the patients with polypharmacy. In the
United Kingdom for instance, there is currently 100% take-up of electronic patient records in
large practice, with high rates of utilization moreover seen in several other developing
nations. Searches to distinguish patients with polypharmacy that may have taken hours (or
even days) to finish with paper-based records would now be able to be done in minutes. In
the future, by linking the primary care records with the records of hospital admission, it can
further contribute to improve this practice by the identification of people who had an acute
hospital admission from a drug reaction or an ADR.
A retrospective study in Bhopal was conducted by collecting prescription of professionals in
numerous tiers of health care. Patients attending the clinics of specialists were approached at
pharmacy shops and asked to show their prescriptions and with the aim of taking prior
consent of the patient‘s prescriptions which had been copied. This study involves
administration of bilingual i.e. English/Hindi questionnaire which includes the following
details.
A. Patient information like name, sex, age etc.
B. Physician name, specialization and qualification.
C. Prescription date
D. Current medical condition, sign and symptom and medical history of the patient
E. Current prescription medication which includes drug, dose, frequency and indication.
F. Current nutritional supplement and drug product
G. Dosage regimen
Questionnaires have been completed through semi-established interviews with patients at
their respective health care centers and clinical store. Data which was obtained showed the
following outcomes.
A. Over prescribing, useless use of drugs (to prescribe excessive or unnecessary remedy that
isn't beneficial for sufferers).
B. Repetitive use of drug, incorrect drug combinations (medicinal drug is one which has more
ability to harm than to benefit the patient and do not agree with standard medication).
C. Drug-drug interactions, food-drug interaction.
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D. Over prescribing, inappropriate use of medication
Of all the prescriptions, 2.38% (N=326) confirmed over prescribing. There has been
purposeless (60%) use of tonics for the patients. Multivitamin and tonics formed an essential
part for maximum prescriptions.
A combination of metronidazole + albendazole + mebendazole was prescribed together for
diarrhea infection indicating the misuse of anti-amoebic.
A combination of cotrimoxazole + chloramphenicol + ampicillin + furoxone was prescribed
for a case of typhoid fever. Such multitherapy has resulted inside the emergence of
Salmonella typhi-resistant to many drugs in a number of Indian towns.
Cases of the common cold are self-limiting and need management with the help of
symptomatic therapy. There is not any healing utility of ordinary administration of antibiotics
because the common cold is due to a virus. The antibiotics erythromycin and amoxicillin may
be administered only if there may be the prevalence of fever.
Repetitive drugs, inappropriate drug combinations
Of all of the prescriptions 3.96% [N=326] of the prescriptions confirmed repetition. One of
the placing features of the look was the duplication of medicine within the prescription,
which causes inadequate dosage or quantity of medication prescribed.
Anti-inflammatory pills were reiterated in the prescription, e.g. acetaminophen +
chlorpheniramine + pseudoephedrine combination was prescribed two times as sinarest and
thrice as rhinoset for 3 days.
In study, it was found that two to three multivitamin preparations had been prescribed for the
same patient leading to duplication.
It shows adoption of polypharmacy promoting needless use of tonics, overlooking drug
interaction and growing the price of therapy and incidence of aspect effects. In case of
breathing problems, there may be excessive use of cough combinations which add to the
price of therapy.
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Drug-drug interactions, food drug interaction
Of all the prescriptions 2.39% [N=326] of the prescription showed drug-drug interactions.
Iron salt was prescribed with norfloxacin regardless of the fact that iron salt lowers the
absorption of norfloxacin.
Levofloxacin and Gatifloxacin had been prescribed with NSAIDS like Paracetamol and
Nimesulide without any notification to adopt precautionary degree against convulsive
seizures.
Multivitamin instruction containing Iron may additionally decrease the absorption of
levofloxacin whilst co-administered.
So, it was concluded that the frequency of polypharmacy among patients in the region of
Bhopal taking inappropriate prescription medications is found to be 8.73% [N=29].
Of all prescriptions 2.38% [N=326] shows over prescribing drugs, 3.96% [N=326] showed
repetition of the drugs, 2.39% [N=326] showed the drug-drug interactions.[25]
Polypharmacy is a widespread concern and doctor, clinical pharmacists, and patients are all
responsible. Physicians are expected to be very ignorant to pharmacological interactions of
the medication alternatively indulged within the malpractices. Therefore, variety of
orientation programs and continuing scientific education etc. must be attended by the
practitioners as a habitual exercise. Physicians should be aware of the frequency of dosing
and the number of medicines the patient is taking, and their pertaining to compliance.
Attention should be paid regarding the mechanism of the drug so as to avoid duplication of
medicine.
Sufferers can also contribute to the trouble via self-medicating, failing to observe prescribed
directions, failing to file all medications or OTC product used, and borrowing or buying and
selling medicine to additional individuals. Patient should be aware of alternative therapies. It
is essential to consider that the effects of inappropriate polypharmacy may be particularly
massive to an elderly patient's well-being, economic security and potential to adhere to the
prescribed remedy.[26]
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IMPACT OF POLYPHARMACY IN GERIATIC PATIENTS
A prospective observational study was carried out in the department of Medicine and
Emergency, SSIMS and RC, Davangere for 6 months, from September 2016 to February
2017. Ethical clearance was obtained from the institutional ethical committee (IEC) of Bapuji
Pharmacy College.[27]
All inpatient of more than 60 years of age in emergency and medicine wards undergoing
polypharmacy, irrespective of sex were included and the patients admitted to the ICU, with
malignancy and those who passed away during the period of treatment were excluded in the
study.[28]
The cases obtained were analysed using the commercially available ―Micromedex‖.
In this study a total of 150 patients were incorporated. Out of 150 prescription that were
analysed, it was shown that majority of the patients were between 60-69 years followed by
70-79 years. The other age group (≥80 years) was found to be less (Table 2).
According to the analysed data, it was found that major polypharmacy was common in the
hospitalized patients as 90% of the patients were given >5 drugs during their stay in the
hospital and was categorized as a major reason for polypharmacy. According to the study
most commonly prescribed drugs were cardiovascular drugs (22.09%), gastrointestinal drug
(20.33%), antimicrobial drug (19.05%), analgesics (8.97%) and hypo-lipidaemic (4.9%)
(Table 3). It was found that drug-drug interaction got increased with increased number of
drugs. A total of 320 drug interactions were found. By doing severity assessment of the drug
interaction it was found that 62.82% of drug-drug interactions were moderate and 8.75%
were severe. Azithromycin, Levofloxacin Ondansetron was frequently involved in severe
drug-drug interaction. Furosemides, Aspirin Digoxin, were often responsible for moderate
drug-drug interaction[29]
(Table 4).
Table 2: Age wise distribution of patients.
S.no Age(years) Number Percentage (%)
1 60-69 102 68
2 70-79 35 23.33
3 ≥80 13 8.67
TOTAL 150 100
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Figure 1: Percentage of age wise distribution of Patients.
Table 3: Different Classes of Drugs Prescribed to Admitted and Discharged Patients.
S.no Drugs Admission Percentage (%) Discharge Percentage (%)
1 GI drug 127 20.32 64 14.71
2 RS drug 50 8 79 18.16
3 CVS drug 138 22.08 99 22.76
4 Antibiotic drug 119 19.04 92 21.15
5 Endocrine drug 10 1.6 4 0.92
6 Analgesic drug 56 8.96 23 5.29
7 Hematological drug 7 1.12 3 0.69
8 Vitamin & Mineral,
supplements 41 6.56 29 6.67
Figure 2: Different classes of drug prescribed to admitted patients.
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Figure 3: Different classes of drug prescribed to discharged patients.
Table 4: List of potential drug-drug interactions
S.no List of all drug- drug interactions No. of times occurs in the study Percentage
1 Azithromycin + ondasetron 7 25
2 Levofloxacin + ondasertron 4 14.29
3 Rabeprazole + clopidogrel 4 14.29
4 Ceftriaxone + heparin 2 7.14
5 Clonidine + metaprolol 2 7.14
6 Cefpodoxime + heparin 1 3.57
7 Phenytoin + rabeprazole 1 3.57
8 Fluconazole + clopidogrel 1 3.57
9 Losartan + aspirin 1 3.57
10 Omeprazole + clopidogrel 1 3.57
11 Amitriptyline + ondansetron 1 3.57
12 Piperacillin + enoxaparin 1 3.57
13 Amiodarone + digoxin 1 3.57
14 Ramipril + telmisarton 1 3.57
15 Total 28 100
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Figure 4: Percentage of potential drug- drug interactions.
POLYPHARMACY IN VARIOUS SETTINGS
Ambulatory Care
In ambulatory care, medicinal count of five or more medicines is defined as polypharmacy.
However, current guidelines of medical practice state multiple medications to deal with
chronic state of diseases for optimum clinical benefit. An aged person encountered with two
serious disease states usually exceeds the arbitrary threshold of more than five medications.
For example, a study of year 2005-2006 from the USA by Qato et al used a populace-based
survey of community living persons 57-85 years of age. Out of them, 37.1% of men and 36%
of women in 75-85 years age group were taking at least 5 prescription medicines. This older
age group who were taking at least one prescribed drug, 47.3% reported use of over the
counter medicines and 54.2% a nutritional supplement. The use of inappropriate medicine
was studied in about 128 male outpatients in United States out of which 58.6 patients took
unnecessary prescribed medication.[30]
Hospital Setting
There are very few studies that have inspected the concern of polypharmacy in the
hospitalized elders. A study by Hajjar and colleagues consisting of 384 patients was
examined, out of which 41.4% were on minimum use of at least 5-8 medications, & 37.2%
were on 9 or more.[31]
Overall 58.6% of patients took one or more inappropriate prescribed
medication. An Italian study which was conducted in 2011, examined the frequency of
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polypharmacy in the hospital at both admission and after discharge.[32]
They concluded that
on admission 51.9% of patients had been on more than 5 medications with a mean of 4.9
medications and 5.2 diagnoses. At discharge this rate accelerated to 67% with a mean of 6.0
medicines and 5.9 diagnoses.
Nursing home setting
Polypharmacy in nursing homes has turned into an ongoing subject over the last four
decades. A study from data obtained in 2004 from a survey in nursing home at United States,
shows that 39.7% had defined polypharmacy by this quality meter measure.[33]
The lowest
rate of polypharmacy turned into those patients aged 85 years or older (34.8%). A study from
Canadian nursing home reported that only 15.5% patients were placed on more than nine
medications.[34]
How polypharmacy can be managed
Accurate medication and medical history of the patient should be maintained carefully which
includes OTC medicines, complementary medicine etc. and by knowing all the information
will help the prescriber to deter any additional therapy. Further knowledge of a specific
medicine can describe patient specific symptoms or complaints. For e.g. knowing if a patient
is placed on an opioid analgesic may also describe why he/she has constipation. Figuring out
patient clinical records permits the pharmacist to identify inappropriately prescribed
medications. For instance, metformin is not suitable for patients having end stage kidney
failure.
Reducing pill burden is an appropriate step to reduce polypharmacy as high pill burden
decline compliance with the drug therapy. It also increases instance of ADR and drug
interaction. It is also linked to increased risk of hospitalization, medication error and
increased cost of treatment. This can be achieved through "deprescribing" in which the both
risk and benefit are measured when considering whether to continue the medication or not.
For e.g. bisphosphonate which is used to treat osteoporosis is often used indefinitely although
the evidence which is present is of 5-10 years. It can also be reduced by choosing long acting
active ingredient over short acting active ingredient. For e.g., angiotensin converting enzyme
inhibitor (ACE) are used in treatment of hypertension. Both captopril and lisinopril are
examples of ACE inhibitors. However, dose of lisinopril is once a day, whereas captopril can
be dosed 2-3 times per day. Assuming that no contraindications or potential for drug
interactions is using lisinopril as compared to captopril can be an appropriate way to reduce
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pill burden. Basically, it is an identification and discontinuation of the of medication if the
benefit of the medicine fails to outweigh the harm of the same medicine. In older patients it is
commonly done as a patient becomes feebler and treatment focus shifts from preventative to
palliative care.
Each prescribed medication should be linked with disease state i.e. each medication which is
prescribed should be matched with the patient diagnosis. If the medication does not match the
patient diagnosis it is potentially pointless and attempts should be made to discontinue it.
Prevention during prescription can reduce polypharmacy. The relevance of the medication to
the patient and its potential for side effects should be considered. Any drug whose use is
unnecessary, inappropriate, or has a high possibility for producing side effects that would
require additional treatment should be avoided.
Reconcile medicinal drugs upon discharge from the health center or skilled nursing facility.
As noted above, a threat element for polypharmacy consists of current hospitalization. The
transfer of an affected person from a medical institution to his or her home is related to
negative events and poor results, most of which might be related to changes in the patient's
drug remedy during treatment in those facilities. Evaluation of the patient medication remedy
and educating an affected person upon discharge from a facility will reduce replica therapy,
inappropriate prescribing, and decrease the use of unnecessary medicine.
CURRENT AND FUTURE PERSPECTIVES ON THE MANAGEMENT OF
POLYPHARMACY
Polypharmacy includes taking a multitude of medicine, it can be prescribed medicine, OTC
drug, complementary medicine or a dietary supplement which can cause not only harm to the
patient but is also dangerous.
So, it becomes very important to mitigate the risk of unwanted drug interaction and to
increase the drug adherence to the essential drug.
For majority of the countries access to the drugs and their affordability abound. It is also
important to note that the average life span of humans have been increased as compared to
the past. For e.g. in the United states the percentage of aged population of 65 years or older is
projected to rise from 12.4 percent in 2000 to 19.6 percent in the year 2030. Also, it is
calculated from year 2000 to 2030 that the worldwide population aged 65 years or more is
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expected to rise from 550 million to 973 million.[35]
As due to increase in life expectancy,
chances of prevalence of the chronic medical condition such as cardiac vascular disease,
arthritis, cancer etc. also gets increased.
Success in the pharmaceutical research and its progress to bring in the market the treatment
of chronic and common disease and the willingness of both the government and consumer to
pay for it also give rise to the polypharmacy.
It is also common in developed countries like the United Kingdom, as the population
becomes old, it in turn increase the risk in people with long-term conditions. This increases
the pressure on the physician to follow the evidence-based guidelines for managing the
chronic condition such as those framed by the national institute for health and care excellence
(NICE) in England.[36]
Traditionally this guideline is based on single disease and not often
considered multimorbidity. Therefore, patients with co-existing medical condition may end
being provided by different kind of drugs by the physician. For e.g. patient with hypertension,
type-2 diabetes, and osteoarthritis may be prescribed with angiotensin converting enzyme
[ACE] inhibitor, other antihypertensive agent, one or more oral hypoglycemic agent, a statin,
an analgesic and aspirin.[37][38]
The absence of relative up to date evidence-based guideline is the main limitation in the
management of polypharmacy. Considering this point, the developers of guidelines such as
the NICE are developing guidelines which focus on people with more than one significant
chronic condition.[39]
However, development of these guidelines and its impact on patient understanding and
clinical outcome will take time to become apparent due to lack of clinical trial in multi-
morbidity patient. Randomized clinical trials in the past have usually had quite rigorous
choice procedures that resulted in older and frailer patients with multi-morbidity being
excluded.
In the absence of data on the patient subjected to clinical trial, large clinical databases and the
patient registries are also used as an alternative method for generating the evidence related to
both risk and benefit of polypharmacy.[40]
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MANAGING POLYPHARMACY IN PATIENT WITH MULTIMORBIDITY
In the year 2016, guidance on the clinical appraisal and patient‘s management with
multimorbidity (when two or more chronic health conditions are present) were published by
NICE. The main aim of the guide is to deliver the care in a way that considers both
multimorbidity& any associated feebleness in the patients.
This includes many factors, such as.
a. Interaction between the health condition and treatment of the patients how this interaction
affects quality of life
b. Focus on individual need of the person, their preference for the treatment, lifestyle, health
priorities and goals.
c. Focus on improving the quality of life of patients by reducing various things such as
treatment burden, episodes of unplanned care and adverse events.
Guidelines from NICE recommends that the physician should consider the evidences
recognizing both benefits and harms for the individual patient and outcomes should be
positive for the patient. This could be achieved by the use of a screening tool (for e.g., the
STOPP/START tool in the older people) which helps to identify the medicine-related safety
concerns and the use of the medicines by which the person might get the benefit but not
taking currently. Reviewing of the patients plays an important role to monitor the
consequences of any changes made in the prescription, which would include the need that
further changes in treatments are needed [including the restarting of a treatment]. Shared
decision-making process also plays a key part of this guidance; particularly important in
people with feeble or having limited life expectancy who has less capacity to get benefit from
the pharmacological interventions.
RISK PREDICTION TOOL
This tool plays an important role in quantifying the risk associated with adverse drug
reactions, thus provides guidance on managing of patient with polypharmacy.
In the year 2014, a systemic review was published which aim to estimate the quality of
authenticated risk prediction tool for the adverse drug reaction in the people of 65 years or
more.[41]
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The author of the review was able to identify four tools of risk prediction but this entire tool
had limitations and hence their performance was generally uncertain. These tools were
designed by using the data of the hospital inpatient, therefore, it is very difficult to predict
that how these tools work in primary health care and ambulatory settings. Further research is
needed in this risk prediction tools so that it can be useful both for inpatient and
outpatient.[42][43]
EVIDENCE BASED PRESCRIBING
Two systematic evaluations are applicable here, one of which observed in improving the
outcome of people with a long-term condition and the other at improving the best use of
polypharmacy in an older person. Smith et al. recognized 18 significant randomized clinical
trials of interventions that aimed to enhance the management of the person with
multimorbidity and usual capabilities in community settings and primary health care.[44]
They conveyed that there was a deficiency in the evidence regarding the effectiveness of
intervention for people with long term illness due to relatively small number of trials carried
out on this topic so far, and thus this trial has mixed findings. There was some evidence
although of improved health effects if interventions may be centered at vulnerable factors
together with depression or definite functional problems in humans with multimorbidity.
Cooper et al. recognized 12 studies [10 of which were randomized controlled trials] of
interventions which have the aim to improve the use of polypharmacy in older people.[45]
There were various interventional techniques deployed and some evidences which led to
more appropriate polypharmacy [based totally on lower tiers of irrelevant prescribing].
However, it was not known whether these interventions caused critical clinical improvement
(for instance, a reduction in emergency medical institution admission).
OPTIMISING THE USE OF DRUG
Optimizing the use of drug is a very important step in reducing the danger to the patient from
the use of unsafe and inappropriate medicine.[46]
All prescribes should carefully consider both
the potentials prices as well as the benefits of the treatment before starting the medication and
should be aware of the risks of over-treatment, adverse drug reactions and drug interactions.
Recently, health systems and professional societies have targeted on producing the guidelines
related to single-disease and only some progress has been observed in developing the
guidelines for dealing with patients with multimorbidity. Tools which are used to promote
shared decision-making by physicians and patients also are a comparatively new
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development. In recent years, many initiatives such as International Patient call Aids
[IPDAS] collaboration, the Dutch call Aids Implementation Programmed the center for
informed choice has been taken in the USA.[47]
Prescribers should have systems for the monitoring of the prescription and regular review of
the patients. The use of electronic patient records can help to facilitate the monitoring of the
patient. Professional teams such as pharmacists, physician assistants and specialized nurses
can also support the physician for both monitoring and reviewing of patient. General practice
is forward view in England, aims to provide the necessary investment to employee such as
non-medical skilled teams to support general practitioners, thereby freeing up physicians‘
time to target additional complicated patients.[48]
.
An intervention by using the information from coupled automated medical records showed
that intervening in primary care practices will considerably reduce rates of risky prescribing
of medicines. The administrative study in 33 medical practices with a registered population of
around 2 lakh patients within the Tayside region of Scotland also showed that the amendment
in prescribing patterns caused significant reductions in connected emergency admissions to
the hospital. Study team reviewed the patients‘ exposure to high risk prescribing of non-
steroidal medicine medication [NSAID] or antiplatelet agents. This enclosed prescriptions to
individuals with nephropathy or heart condition, or prescribing to individuals taking
anticoagulant medication like warfarin, 48-week intervention comprised skilled education,
informatics to facilitate the assessments of patient treatment, and small monetary incentives
for practices to review patients. These interventions resulted in approximately 37% reduction
in the risky prescribing, and this improvement was maintained even when monetary
incentives to review patients were withdrawn. There was also an associated decline in the rate
of hospital admissions for ulcer or hemorrhage, and for a heart condition.
COGNITIVE COMPUTING AND ARTIFICIAL INTELLIGENCE
In the longer-term, it's attainable that we could see the utilization of ―machine-driven
analytical techniques‖, ―deep learning methods‖ and ―artificial intelligence‖ technologies
developed by firms such as ―DeepMind‖ may even be applied during this space.[49]
One
example of this is a research project to enhance the detection of acute kidney failure, several
cases of drug-induced diseases and those who are a major reason for mortality and morbidity
globally. Using the techniques to incorporate and analyze clinical information from a
diversity of sources, DeepMind aims to mechanically determine patients with acute kidney
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injury and inform their clinicians promptly; thereby aiming in early detection of acute kidney
injury and giving clinicians the chance to alter a patient‘s clinical management. Similar
strategies could even be used to risk stratify patients to detect those at higher risk of
complications, therefore giving their clinical groups the choice to switch their patients‘
treatment to decrease this excessive risk. A related space is the development of ‗cognitive
computing, often being pioneered by firms such as IBM, using its Watson Health Platform to
support clinicians to optimize both the treatment and prescribing selections for the patients.
The Watson platform is centered on natural language processing and on the machine learning
of high volumes of unstructured clinical information. Though technologies like cognitive
computing and artificial intelligence still lies in the very early phase of the development,
considerable money investments are done in this field by firms like Google and IBM. It
appears inevitable that in future years such technologies can become more and more common
in health care settings radically dynamic the means within which doctors and alternative
health professionals work; furthermore, giving patients a lot of support within the
management of their long-term conditions and in optimizing their health.[50]
MEDICINE RECONCILIATION
It is one of the key areas in the management of polypharmacy. In this process patient
medicine orders with all the medication that the patient has been already taking are being
compared so that various types of medication error can be avoided such as duplication,
omission, dosing error or drug interaction. Medicine reconciliation should be done at every
change i.e. transition of care which includes changes in service practitioner, settings or level
of care in which new drugs are prescribed or existing order are revised.
This process consists of five steps.
a. Making of current list of medication
b. Developing the list of medication which has to be prescribed
c. Comparing the medications on the two lists
d. Take appropriate clinical decisions which is based on the comparison
e. Tell the new list to appropriate physician or other medical staff and to the patient. In year
2016 systemic review & meta-analysis of medicines for reconciliation was published which
revealed that medicines reconciliation can decline the adverse drug events and related risk of
emergency units and re-admissions to the hospital.
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Another important step in reducing the risks in polypharmacy is to improve the discharge
method for patients this can be done by discussing every information regarding discharge
with the patient and his/ her family member and they should be given a copy of the discharge
summary. By having the satisfactory coordination between community health services,
hospitals, physicians and social care service providers, there should be the follow up of the
discharged patients who have high risk of complication and medicines reconciliation process
should be carried out.[51- 53]
MANAGEMENT OF SIDE EFFECTS
Side effects from medicine are common, highest in patients with polypharmacy. Previous
analysis has shown that a lot of patients do not report the side-effects of the medicine to their
physicians; and once they do inform their physicians, these side-effects usually are not
recorded in patients‘ medical records and do not get reported to regulative authorities.
Previous analysis has shown that physicians prescribing new medications typically do not
convey the necessary medication-related data to their patients and this area of practice must
be improved. A physician-targeted academic session within the USA has improved the
content and increased patients‘ ratings of communication with physicians about new
medication prescriptions.[54]
Education of patients can in turn improves their responsibility in
reporting side-effects to the physicians and can enhance the communication.[55]
New smart
phone applications aiming towards patients with chronic conditions have the potential to
assist with the recording and management of drug side-effects. However, their use requires
further analysis as do systems for permitting patients to self-report drugs aspect effects to
national pharmaceutical regulative organizations.[56]
INVOLVEMENT OF PATIENTS
A key element of addressing the risks related to polypharmacy is to make sure that patients
are fully involved in both the process of starting the medicines as well as in the process of
monitoring their use of medication to make sure appropriate adherence to their prescribed
drug regime. This can help in informing patients regarding the risks of their medication, also
as its benefits.[57]
One negative impact of giving patients ‗too much‘ information is that they will then
discourage from taking a drug owing to considerations regarding its side-effects. Tools which
are used to promote shared decision-making can help to overcome such considerations and
improve patients‘ adherence to their planned management arrangement by providing
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information regarding the advantages and risks of medicines in a format patient can
understand simply. Awareness of the link between patients, their health services and social
networks, as within the ‗Burden of Treatment‘ model represented by May and colleagues can
also help in increased patient‘s adherence to their medication.[58]
In recent years, we have seen the development of smart phone applications akin to the ―My
Medication Passport‖ to increase the communication between patients and aid professionals,
helps to improve people‘s understanding of their conditions and their treatment and in
maintaining a record of changes created to patient‘s medication.[59]
These smartphone-based
tools do show promise – as they are based to give patients online access to their electronic
medical records. However, such technologically-based interventions demand rigorous
analysis to work out if clinicians, patients and healthcare can use them and to confirm that
they are cost effective.[60]
For e.g. a review of smart phone applications for patients with
respiratory illness found a number of errors in several of them and an absence of compliance
with current clinical guidelines.[61]
One vital limitation of the utilization of information technology primarily based tools is that
older patients – are the most vital target for interventions to enhance prescribing –are
minimum expected to use them. This will change over time as devices like smart phones
become more widely used but currently, clinicians will also have to use paper-based tools for
such patients if they're unwilling or uncomfortable with using information technology-based
tools.
VULNERABLE GROUPS
People living in care homes are possibly the feeblest and most, vulnerable group within the
community. They are likely to be on multiple prescription drugs and also associated with
high-risk of complications from inappropriate prescribing. According to the scientific review
of studies that aimed to enhance prescribing for individuals living in care homes concluded
that there is even no single interventional strategy that have proved to be effective. The
interventions examined enclosed pharmacist-led medication reviews, employee‘s education,
multi-disciplinary team conferences and computerized clinical decision support systems.
There was some proof that a multi-faceted approaches to optimize prescribing that used more
than one intervention was likely to achieve success than one intervention. Owing to lack of
evidence this area would be benefited from more research.[62, 63]
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The use of specialized computerized clinical decision support systems which can use the data
from electronic patient records is an associate degree avenue that should be explored.
However, so far this system has provided only the limited data regarding the benefits and thus
needs further research work.
CONCLUSION
Polypharmacy has increased in recent decades and will continue to rise with the increase in
life expectancy, increase in population age and with the rise in number of people with
multimorbidity. So, it has become very important to focus on high risk individuals by doing
appropriate regular monitoring and targeted reviews which can help to address the high risk
of the adverse event associated with the polypharmacy. Pharmacist, physician assistants,
special nurses or other medical staff can play a key role in the management of polypharmacy
by making complete use of benefits from electronic patient records. It is also the duty of the
physician to ensure that patient is fully involved in decisions regarding their prescription and
in the monitoring of their medical condition. Simple tool such as ―dosette boxes‖ can help the
patients to use their medication properly in a day. Various types of tools and technologies are
available to manage polypharmacy such as the development and use of electronic patient
records - particularly in the primary care settings in which majority of prescribing takes place
and makes patients monitoring more straightforward as compared to the past. It is also used
to identify sub-groups of patients associated with high risk of adverse drug events and
complications. It also helps to facilitate 'deprescribing‘, the process by which the prescribed
medications are reviewed and stopped if not beneficial in terms of clinical use. The
development of the smart phone applications recently has helped to improve communication
between the patients and healthcare professionals. It has also enhanced the people's
understanding of their conditions and their treatment and also helped to maintain a record of
changes made to the patient's medication. In the longer term, introduction of artificial
intelligence and clinical decision support systems have the potential to improve prescribing
and reduce the risks associated with polypharmacy. Further research is needed to be done on
a regular basis to manage a patient with multimorbidity. For this purpose, various types of
clinical trials, systemic review, retrospective, meta-analysis study need to be done.
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