Polypharmacy in patients with chronic illnesses

By Ezra Tumusime

Polypharmacy, also known as polypragmasia, refers to multiple drug consumption or excessive use of medication without indication. According to current scientific data, it can also be defined as regularly and concurrently taking five or more medicines.

Ultimately, Polypharmacy is an umbrella term used to describe the simultaneous use of multiple medicines by a patient for their multiple conditions (multimorbidity), especially the elderly (>65 years of age).

This article, therefore, aims to review the dangers of polypharmacy, strategies to reduce it and skills to improve medication use management, given that it is a challenge for all healthcare providers.

Commonly over-prescribed medicines 

The Journal of Clinical Medicine Research (2019), revealed that the most common over-prescribed drugs include Pain relief medicines (e.g. Panadol, Ibuprofen, Diclofenac, etc.), Medicines for acid reflux such as Magnesium Trisilicate, Hormone Replacement Medicines (e.g., levothyroxine), and Antidepressants (e.g. Amitriptyline), depending on your stage of life, especially older adults.

It is also common in patients taking Opioids for the long term, whereby interacting medications such as benzodiazepines (e.g. Diazepam, commonly known as Valium), are co-prescribed. Polypharmacy with opioids and benzodiazepines (e.g. Diazepam), may increase confusion, risk of falls, and hip fracture.

High-risk medicines: Anticholinergic drugs (e.g., diphenhydramine, commonly found in cough syrups), in older adults are given in many conditions such as Chronic Obstructive Pulmonary Disease (COPD). They are known to cause dizziness, tiredness, permanent perceptive damage, death and other symptoms that can impact a patient’s quality of life.

Factors contributing to polypharmacy

Multi-Morbidity: A situation of having 2 or more chronic conditions, which is common with the elderly population as a result of changes in their body organ functioning.

Prescribing Cascades: It refers to the prescription of additional drugs to treat other drugs’ side effects by misinterpreting them as a new condition. 

Use of Over-the-Counter (OTC) and Complementary Medications: These are medications that a patient can acquire without prescription or knowledge of their medical providers e.g. painkillers, cough lozenges, supplements, herbal medicines, etc.

Transitions of Care: Transfer of the patient between hospital and home or an institutional setting such as a nursing home, are a common source of medication errors and exposure to polypharmacy. 

Implications of Polypharmacy

Drug Side Effects: Undesired effects of medicines at the usual dosages, e.g. nausea, vomiting, abdominal discomfort, skin rash, etc.

Drug Interactions: These are reactions between two (or more) drugs or between a drug and a food, beverage, or supplement(s) when used concurrently.

Non-Adherence to medications: It simply means failure to take medications as prescribed by the Health provider. It can be as a result of polypharmacy due to the associated side effects, resulting in treatment failure and frequent hospitalizations.

The risk of Hip Fracture: Polypharmacy may predispose to prescription of multiple medications including Psychotropics (Drugs which act on the brain and spinal cord), which are commonly associated with falls. 

.Changes in Pharmacokinetics Associated with Aging: Pharmacokinetics simply means drug absorption, distribution, metabolism and excretion (what the body does to the drug). These processes are affected in elderly /terminally ill patients as a result of age/debility-related decline in the functioning of the organs involved. This results in increased susceptibility to adverse effects of drugs. The toxicity of drugs increases with polypharmacy, especially in the elderly and multimorbid patients due to poor elimination of drug metabolites from the body.

Age-Associated Changes in Pharmacodynamics: How the drug reacts with the body varies with age, but the changes are specific to the drug studied and the effect measured.

Strategies to Prevent Polypharmacy

A: The Patient’s responsibilities;

Spend time with a primary doctor or any medical provider to discuss with you about your medicines and your quality of life. He/she can identify the unessential medications you are taking and report back to your primary healthcare provider and together they may take them off so as to minimize the side effects. But your primary doctor can also determine whether you’re on medicines that are no longer helping you. How should they do this?  

Figuring out if you’re taking too many medicines: Your primary doctor can review your medical records at every visit to remove unnecessary medicines. 

Your list of medicines: Maintain an accurate medication list, medical history and update whenever possible. Always carry all your medications (Prescription medicines, OTCs, supplements and herbals, (if any), at every visit. 

Timing: Have you been taking a particular medicine for a long period of time, without a break? Do you still need to keep taking it? Maybe the benefit of the medicine has run its course and could be stopped. 

B: The Healthcare Professionals’ responsibilities; 

Every healthcare worker, must regularly determine what medications each patient takes. Duplicate medications require removal from the patient’s regimen after consulting with the clinician who initially prescribed them. The date of prescribing and duration must be stated during each clinic visit. If a nursing staff suspects duplicate therapy, they should consult with a pharmacist and bring it to the prescriber’s attention. This calls for Interdisciplinary Teamwork (IDT), i.e. Consultants, Doctors/Clinicians, Palliative Care Specialists, Pharmacists/Dispensers, Nurse Practitioners, etc.

Take home message 

The care of older adults can be challenging because they may require multiple medications to manage their complex medical problems. Therefore, optimizing their medication regimen is one of the critical elements in comprehensive geriatric and palliative care. Preventable adverse drug events are one of the serious consequences of polypharmacy, and this possibility should always be considered when evaluating an older patient with a new symptom until proven otherwise. This strategy can prevent prescribing cascades and even the risk of hospitalizations.

Also, being aware of specific issues related to polypharmacy, like increased risk for hip fractures, falls, and decreased cognitive functions, can help avoid a lot of negative outcomes like falls and decrease health care costs.

While prescribing multiple medications cannot be avoided in a specific patient scenario, healthcare professionals should aim for a balance between over-prescribing and under-prescribing and consider medication appropriateness based on life expectancy and care goals.

About the Author; Ezra Tumusime is a Palliative Care/Medicine Specializing Student at IHPCA/ Makerere University Kampala (MUK) & a Practicing Senior Clinician at SODC-Mbuya. Email: ezra50t8@gmail.com