Polypharmacy & The Medication Review Process
By Greta Goldshtein, PharmD, APh, November 28, 2018
Polypharmacy is a general concept referring to the concurrent use of 5 or more medications by the same individual, often with the connotation that some number of prescriptions are clinically inappropriate (e.g. therapeutic duplications, drug-drug or drug-disease interactions, high risk of side effects).
Prescription drug use is rising in the United States, outpacing population growth. According to a nationwide survey published in Consumer Reports in August 2017, the number of prescriptions increased 85% over 20 years, while the population grew by 21%. Some of the increase stems from polypharmacy as 77 million baby boomers reach their 70s. A study by Qato and colleagues published in the April 2016 JAMA Internal Medicine found that among adults with a mean age of roughly 71 years, 35.8% take at least five prescription medications, and 67.1% take five or more medications or supplements of any kind, including OTC medications.
The risk factors are multiple chronic disease states and polymorbidity, transitions of care, and seeing a number of different prescribers. The exacerbating factors include prescribing cascades, lack of communication among providers, and lack of education for patients. A therapeutic cascade occurs when an emerging side effect of a medication necessitates additional therapy, increasing the overall pill burden and opening up the possibility of additional side effects or drug interactions. Over-the-counter medications and supplements are underappreciated as a source of therapeutic problems.
The increasing incidence of polypharmacy is of particular concern in older individuals as it has been associated with multiple adverse consequences: increased direct and indirect health care costs and increased risk of poor clinical outcomes (bleeding, renal failure, falls, fractures, depression, cognitive and functional decline, delirium, and overall mortality).
Due to time and staffing constraints, health care professionals may fail to obtain a complete medication history with times and manner of administration and then to thoroughly analyze the gathered data for potential compliance problems, drug-drug, drug-supplement, and food-drug interactions, as well as other issues.
Polypharmacy can be evaluated using the combination of Beers Criteria, Screening Tool to Alert doctors to Right Treatments (START), Screening Tool of Older Person's Prescriptions (STOPP), and the Medications Appropriateness Index (MAI).
A regular medication review process should be undertaken to collect and update information on all medications taken by a patient so that each drug can be checked for potential need for adjustment or discontinuation. Pharmacists are particularly trained and qualified to perform this detailed analysis and to affect positive clinical outcomes in consultation with the prescribing clinician.
Leelakonok N, Holcombe AL, Lund BC, Gu X, Schweizer ML, Association between polypharmacy and death: A systematic review and meta-analysis. Journal of the American Pharmacist Association. 2017. 57(6):729-738