Polypharmacy: When is many, too many?

With advancements in healthcare, the size of the elderly population (age > 65 years) is growing globally. According to data from World Population Prospects: the 2019 Revision, by 2050, one in six people in the world will be over age 65 (16%), up from one in 11 in 2019 (9%).¹ At the same time, the population of young people with complex mental and physical health conditions has also increased. Both population subgroups are extremely vulnerable to the dilemma of polypharmacy, defined as concomitant ingestion of 4 or more medications.² Polypharmacy, while advantageous in some disease conditions and unavoidable in others, may pose risk of medication related adverse effects.

In a recent study, the prevalence of polypharmacy among people aged > 65 years was found to be 28.9% in women and 17.2% in men.³ Another study found that the prevalence of multimorbidity and polypharmacy in patients with urogynecological complaints was significantly high, 85.8% and 58.4% respectively.⁴

Multiple factors contribute to the occurrence of polypharmacy in women with urogynecological problems. These are increased incidence of chronic diseases, wider availability of effective drug treatments, treatment by multiple subspecialists who follow guidelines that recommend the use of one or more medicines for prevention, and treatment of various health conditions.⁵ Most guidelines talk about how to start treatment but rarely discuss when and how to stop them, acting as a driving force for polypharmacy.²

Polypharmacy can act as a barrier to compliance because of associated complex medical regimens, increased risk of adverse drug reactions and increased cost to the patients. Increased adverse effects can lead to further addition of medications to treat those adverse effects leading to ‘prescribing cascade’.⁶ It can also to lead to increased risk of falls especially in the elderly population. This association may be partly due to the disease for which the medications have been prescribed and partly due to polypharmacy.⁶ Centrally acting drugs, anti-allergic, anti-cholinergic, and cardiovascular medications when given in combination are likely to increase the risk of fall. Another important issue is continuation of effective medications in the elderly even after the condition has been resolved and non-pharmacological measures could have sufficed. For example, continuation of antibiotics in elderly women even after the recommended course because of the fear of recurrent UTI, overuse of anti-cholinergics without lifestyle changes, and long-term continuation of Gabapentin for neuropathic pain even after resolution of symptoms. All these instances can increase the risk of disability and adverse drug reactions, especially in frail patients.

There are many tools for assessment of polypharmacy, both explicit and implicit. Explicit tools have the advantage of being clear, quick, and easy but do not take patient complexity into consideration.

Implicit tools are more time-consuming because they are based on physician judgment rather than set criteria, but they are more patient-centered and consider patient complexity. These tools allow for comparison of a patient’s medication list to list of potentially inappropriate medications, check for medication duplication, drug interactions and adverse effects.²

An important step in managing polypharmacy is deprescribing, defined as a “systematic process to identify and discontinue medications if existing or potential harms outweigh potential benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values, and preferences”.⁷ When prescribing for old and frail patients it is best to coordinate with others involved in the treatment, review the medications regularly and ask about the impact of the drug on patients’ functions and quality of life in every visit. The time needed to achieve the outcomes relative to the patient’s life expectancy should also be kept in mind. Emphasis should be given to non-pharmacological measures like weight loss, lifestyle changes, fluid and diet modifications and exercises wherever possible so that the need for excessive medications reduces.

In patients with multiple comorbidities, appropriate polypharmacy may be advocated. It refers to prescribing for an individual with complex or multiple conditions where medicine use has been optimized and prescribing is in accordance with best evidence. To be able to differentiate between ‘many’ medications and ‘too many’ medications is one of the greatest health care dilemmas and the only way forward towards optimal patient care is to find that fine line.

REFERENCES

1. World population prospects report 2019, UN.
2. Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018 Sep 3;9(9):CD008165. doi: 10.1002/14651858.CD008165.pub4. PMID: 30175841; PMCID: PMC6513645.
3. Cebrino J and Portero de la Cruz S (2023) Polypharmacy and associated factors: a gender perspective in the elderly Spanish population (2011–2020). Front. Pharmacol. 14:1189644. doi: 10.3389/fphar.2023.1189644
4. Zuo SW, Tellechea L, Kohn JR, Chen CCG, Abraham N, Leegant A, Halani PK, Laudano M. Polypharmacy and Multimorbidity in the Urogynecology Population and Their Effect on Pelvic Floor Symptoms. Urogynecology (Phila). 2023 Jan 1;29(1):80-87. doi: 10.1097/SPV.0000000000001262. Epub 2022 Oct 15. PMID: 36548108.
5. Cadogan CA, Ryan C, Francis JJ, Gormley GJ, Passmore P, Kerse N, et al. Development of an intervention to improve appropriate polypharmacy in older people in primary care using a theory-based method. BMC Health Services Research. 2016;16(1):661.
6. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315:1096-9.
7. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: Evaluating Risks and Deprescribing. Am Fam Physician. 2019 Jul 1;100(1):32-38. PMID: 31259501.