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OB/GYN Editorial OCTOBER 2005

Polypharmacy: Plague or Panacea?

by Karen D. Novielli, MD

TodayÍs physicians are faced with a prescribing conundrum. Evidence-based literature supports the use of many specific medications to reduce morbidity and/or mortality in patients with a variety of problems. One example is myocardial infarction survivors who experience left ventricular dysfunction. The literature strongly supports the use of statins, b-blockers, angiotensin converting enzyme (ACE) inhibitors, and aspirin in these patients. Diabetic patients also typically have long lists of medications, often requiring multiple drugs to achieve the tight glucose control that has been associated with reduced complications—in addition to consuming the recommended statins, ACE inhibitors, and aspirin to protect the heart and kidneys. Other medications (eg, analgesics, antidepressants) can help to reduce or eliminate disabling symptoms.

All medications have the potential to cause adverse drug events. Multiple medications increase this risk by promoting potential drug-drug interactions and drug-disease interactions. Older individuals are particularly susceptible to the ill effects of polypharmacy, as they often have multiple chronic conditions and age-related pharmacokinetic and pharmacodynamic changes that alter the metabolism, distribution, effect, and side-effect profile of many drugs.1

Although women tend to live longer than men, they also tend to have more chronic conditions as they age, increasing the risk for polypharmacy in this population. Older individuals account for 13% of the US population, yet consume 32% of prescription drugs and have the highest rate of nonprescription drug use as well.2 The average older individual is using 4.5 prescription drugs and two nonprescription drugs daily. Indeed, the risk of hospitalization from an adverse drug event is six times higher in the elderly than in the general population, and up to 30% of hospital admissions in the elderly are attributed to an adverse drug event.3 Lastly, there are many medications that have been labeled ñinappropriateî for the elderly by expert consensus (Beers Criteria) because their risk/benefit profile does not support their use.4 Nonetheless, these drugs are still prescribed for older individuals at high rates, including approximately 25% of the community-dwelling elderly and 40% of the homebound elderly.

What is a physician to do? For many patients, multidrug therapy is clearly critical to their health and well-being, and the risk/benefit profile favors polypharmacy. However, it is also common to see patients who are taking medications of marginal or unproven benefit. Experts offer the following prescribing principles to minimize the adverse outcomes that can be associated with multidrug therapy1:

• Obtain a complete medication history for each patient. This should include allergies, previous treatments and responses, and medications prescribed by other physicians. Ask about all other pharmaceuticals, including over-the-counter medications, nutritional supplements, alternative medications, alcohol, caffeine, tobacco, and recreational drugs.
• Review the medication list, including the list of other pharmaceuticals, at each visit. Check for compliance and effectiveness. Discontinue all medications that are of questionable efficacy.
• Know the medications you prescribe, including their actions, adverse effects, and toxicity profiles. Know how these medications can interact with concurrent diseases and with other drugs, and be alert for these complications.
• Before starting new medications be sure that:
  • You have the correct diagnosis, and that nonpharmacologic therapy has been maximized
  • You have considered whether the symptom in question could be a side effect of another medication, and you have discontinued or changed that medication.
  • You choose the most effective medication with the most favorable side-effect profile at the lowest possible dosage, and then titrate the dose based on tolerability and response.
• Attempt to reach a therapeutic dose before switching or adding another drug.
• Attempt to use one drug to treat two or more conditions whenever possible.
• Use combination products cautiously and only when the need for two drugs has been established and the dosages present in the combination product are the dosages desired.
• Avoid using multiple drugs from the same class or with similar actions.

Active management of multiple medications will be a vital skill for physicians as the population ages and the pharmaceutical industry continues to provide new opportunities and challenges in managing patientsÍ chronic conditions. One recent study found that the major force behind the recent rise in drug spending was growth in medication volume, rather than price increases.5 Indeed, the Pharmaceutical Research and Manufacturers of America Web site boasts that there are currently 146 medications in the pipeline to fight heart disease and stroke.6 It will be increasingly important for physicians to distinguish medications that offer marginal benefit from those that offer the real possibility of reducing morbidity and/or mortality. Sophisticated cost/benefit analyses will be required that consider not only the impact of new medications on specific diseases, but also the value added to already proven therapies and the hidden costs related to the adverse affects of polypharmacy.

KAREN D. NOVIELLI, MD
Associate Advisory
Board Member

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References

1. Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP, eds. Geriatrics at Your Fingertips. 6^th ed. New York, NY: Blackwell Publishing; 2004:9-13.
2. Cobbs EL, Duthie EH, Murphy J, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 4^th ed. Dubuque, Iowa: Kendall/Hunt Publishing; 1999:30-35.
3. Hanlon JT, Schmader KE, Kornkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45(8):945- 948.
4. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US Consensus panel of experts. Arch Int Med. 2003;163(22):2716-2724.
5. Dubois RW, Chawla AJ, Neslusan CA, Smith MW, Wade S. Explaining drug spending trends: does perception match reality? Health Aff (Millwood). 2000;19(2):231-239.
6. Pharmaceutical Research and Manufacturers of America (PhRMA) Web site. Available at: http://www.phrma. org/. Accessed April 28, 2005.

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