Polypharmacy
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Transcript Polypharmacy
Polypharmacy
May 2008 CRIT
Heidi Auerbach, MD
Copyright Boston University Medical Center
Polypharmacy
Definition
Causes
Consequences
Prevention/management
Definition
Suboptimal prescribing
Overuse = Polypharmacy
Inappropriate prescribing
Underuse
Hanlon JT et al. JAGS. 2001;49: 200-9.
Fisk D et al. Arch Intern Med. 2003;163: 2716-2724.
Causes: Age and Chronic Dz
Increased prevalence of somatic complaints
and chronic disease
Community elders- 90% > 1med; 40% >
5meds; 12% > 10meds.
Highest number of drugs per person in
greater than 80 yr olds
Gurwitz JH et al. JAMA. 2003;289(9): 1107-1116.
Causes: Drug regimen
changes
Any transition of care- discharges,ER
New meds, different doses…
Changes from generic to brandnomenclature, color and/or shape
Causes: Providers/Patients
The more the providers and visits, the more
the # meds pt takes
2/3 of all physician visits end with a
prescription
Expectations to receive medication
Not communicating with PCP about med
changes
Self-treatment
Complications of
Polypharmacy
Increased incidence of side effects and
adverse drug reactions (ADRs)
Noncompliance or nonadherence
Increased cost
Side Effects and ADRs
Side effects: considered minor enough to
allow continuation of therapy
Adverse Drug Reactions (ADRs): May
necessitate discontinuation of drug and
require treatment of adverse event
Due to : drug-drug interactions, drug-dz
interactions, drug-herbal interactions, drugfood interactions, rxn to pharmacokinetics or
dynamics, idiosyncratic
ADRs
Elderly 7 times more likely to have
unwanted side effect and 2-3 times
more likely to have ADRs
Multiple meds is the factor most strongly
correlated with increased risk of ADRs
Exponential increase in ADRs with
addition of more drugs to a regimen (2
drugs-15%, 5 drugs-50-60% )
Pharmacokinetics and
Pharmacodynamics
May predispose to side effects and
ADRs
Age-related changes- renal and hepatic
Tend to produce increased risk of doserelated adverse drug reactions which
may be avoided by dose reduction and
careful titration and monitoring of drug
levels (e.g. warfarin, digoxin)
Noncompliance/Nonadherence
Definition
Not taking meds as prescribed
Correlates more strongly with number of
meds, rather than age.
The greater the number of meds, the greater
the nonadherence.
Adherence inversely proportional to
frequency of dosing
Osterberg L, Blaschke T. NEJM. 2005; 353: 487-97.
Factors leading to
nonadherence
Intentional and unintentional factors:
Cognitive impairment/psych issues
Lack of insight into illness
Illiteracy, language/cultural issues
Misunderstanding verbal instructions
Lack of follow up
Cost and other social barriers
Complexity of med regimen
Side effects/ADRs
Statistics on Nonadherence
Elderly: 26-59% with nonadherence
33-69% of drug-related admissions
result from nonadherence (for all pts)
Patients discharged with 4 or more
meds- over 50% error rate
Osterberg NJ, Blaschke T. NEJM. 2005; 353: 487-97.
Omori DM et al. Arch Intern Med. 1991; 151(8): 1562-4.
Direct Cost
Those over 65 make up 12-13% of the
US population and consume roughly 3540% of prescription drugs
Drug prices continue to rise– drug costs
often drive pt choices of health plan and
discretionary noncompliance
Indirect Cost
10-30% elderly hospital admissions are drugrelated
ADEs in 20% of patients on transfers
Estimated 7000 deaths per yr from ADEs
Mean length of stay, cost and mortality double
for pts with ADEs.
Bookvar K et al. Arch Intern Med. 2004; 164(5): 545-50.
Institute of Medicine. National Academy Press. 2000.
Classen DC et al. JAMA. 1997;227:301-6.
Medication Reconciliation
ADEs- Injury resulting from using a
particular drug due to error or from
ADRs.
Multiple categories of error
Prescribing, dispensing, administering,
patient adherence, and monitoring
JCAHO standard to reduce ADEsaddresses specifically errors in
prescribing during transitions of care
Gurwitz JH et al. JAMA. 2003;289(9):1107-1116.
Solutions to Polypharmacy
Review medication
Anticipate ADEs
Avoid errors- prescribe carefully
Give verbal and written instructions
Simplify
Understand obstacles (cost, memory loss…)
Enlist family/nursing/PCP
Make sure there is good follow up
Always Remember
“Prescribing cascade”- a drug added to
treat (mistakenly) the ADR of another
drug
Clinical Pearl- “Any symptom in an
elderly person should be evaluated as a
potential ADR until proven otherwise”
Many geriatric syndromes can occur as
a consequence of medications: delirium,
falls and fractures, incontinence
Take Home Message
Polypharmacy is a reality of prescribing
when patients have multiple
comorbidities.
We must all anticipate and guard
against the potential complications of
polypharmacy.
Optimal prescribing is key!