Avoiding Polypharmacy Pitfalls: It's All in Your Approach

Polypharmacy?which technically translates to "many drugs"?has many meanings. The Health Alliance Plan, a subsidiary of the Henry Ford Health System, defines polypharmacy as "the unwanted duplication of drugs that often results when patients go to multiple physicians or pharmacies."¹ Other researchers implicate anywhere from 5 to 10 drugs as a signal of polypharmacy.^2-5

Pharmacists have legitimate concerns about polypharmacy (Table 1) and frequently try to address it. Nonetheless, the vague definition of polypharmacy contributes to prescribers' eye-rolling when well-meaning pharmacists try to intervene. What pitfalls can pharmacists avoid to improve communication?

Pitfall #1: An Inflexible Definition

Defining polypharmacy with a strict number may deny patients access to necessary drugs. Prescribers may find pharmacists who use number-driven definitions less credible than those who broaden the definition to an outcomes-based assessment. This broader definition involves the question, "Is every drug clinically indicated for this unique patient and prescribed at its lowest effective dose?" If the answer is no, polypharmacy is a problem.⁸

Pitfall #2: Failure to Acknowledge Legitimate Polypharmacy

Some conditions create complex care needs. They cannot be treated with simple regimens. Evidence-based treatment regimens for heart failure, for example, recommend an angiotensin-converting enzyme inhibitor, a betablocker, an aldosterone antagonist, =1 antihypertensives, a diuretic, digoxin, and an anticoagulant.⁹ Diabetic patients need additional drugs. A diagnosis of heart failure has been linked to an increased risk of nonadherence because of the number of drugs needed.¹⁰

Other conditions that frequently require polypharmacy are cancer, mental illness, and hypertension. Polypharmacy is so frequent among the mentally ill that the National Association of State Mental Health Program Directors has identified 5 subtypes¹¹:

(1) Same-class polypharmacy (eg, the use of paroxetine and fluoxetine; this type of polypharmacy is almost always inappropriate)

(2) Multiclass polypharmacy (eg, the use of full doses of drugs from different medication classes to treat the same symptom cluster)

(3) Adjunctive polypharmacy (eg, the use of =1 drugs to treat side effects of another)

(4) Augmentation (eg, the use of a medication at a low dose to augment another, or adding a medication that would not be used alone to treat a symptom cluster)

(5) Total polypharmacy

Legitimate polypharmacy usually is supported by guidelines or treatment algorithms developed by leaders in the field.

Pitfall #3: Ignoring the Patient

A complete assessment for polypharmacy must include a medication history from the patient or the patient's proxy. Using open-ended questions and wellplaced prompts, pharmacists should ask patients about their prescription and nonprescription medication use. One of the most troublesome sequels to polypharmacy is nonadherence. Some key questions to ask are listed in Table 2.

After querying patients, pharmacists should do the following:

• Encourage patients to read all labels carefully and to use only one pharmacy
• Help patients make a comprehensive list of their prescription and OTC medications?including the strength, dose, and duration of therapy
• Indicate to patients that they should carry the list to every physician appointment and update it as medication use changes
• Educate patients that nonadherence often leads to unnecessary medication changes

Pitfall #4: Believing That 2 + 2 = 4

Concomitant use of common and relatively benign drugs often looks fairly harmless. Unfortunately, such is not always the case. Consider a woman who takes calcium for osteoporosis prevention and also takes a proton pump inhibitor (PPI). She takes her whole dose of calcium?1500 mg?with her PPI at bedtime. Taking the 2 substances this way produces suboptimal therapy. The calcium should be split into doses of =500 mg and should not be taken at the same time as the PPI, because calcium works best in an acid stomach. The PPI is best scheduled in the morning. The patient's new regimen should be 500 mg of calcium tid with meals and the PPI every morning.

Pitfall #5: Saving Money on Supplies

After patients have seen the doctor, had prescriptions filled, and been counseled at the pharmacy, adequate prescription bottles and labels will be the most important reminder of what they were told. Pharmacists should use the best-quality product available. "Quality" in this case means that the bottle must be easy to open, yet safe, and be legible for the average reader. (The national retailer Target's redesigned prescription vial, the ClearRx system, is an example of a system that enhances patient safety and compliance.) Including the prescription's indication on the label helps patients, too.

Pitfall #6: Focusing Only on the Elderly

It is common knowledge that elderly people use more drugs than younger people and often require multiple medications. Thus they have an increased potential for adverse reactions, drug interactions, and self-medication errors.

Children who have chronic or serious acute conditions are equally at risk. Although one might think that parental supervision and concern would make adherence in this population excellent, such is not the case. Approximately one third of children and adolescents with serious cancer diagnoses are seriously or occasionally nonadherent.^12,13 The greater the number of children in the family, the less likely total adherence becomes.¹² Similar findings have been documented for children with diabetes,¹⁴ asthma,¹⁵ and Helicobacter pylori gastritis.^16,17 Adolescents tend to consider themselves indestructible or bend to peer pressure. They need more attention and education. Also, pharmacists should remind parents that many OTC preparations for children are combination products. They should encourage parents to call with questions.

Pitfall #7: Not Noticing Red Flags

Certain red flags should prompt clinicians to suspect iatrogenic origin. Conditions that may occur as a result of polypharmacy are listed in Table 3.

Pitfall #8: Fixing It All at Once

It is human nature to want to fix something that looks broken immediately. In the case of true polypharmacy, however, correcting problems requires thoughtful consideration and cannot necessarily be done "today." Discontinuing several drugs at once may have adverse consequences. Some drugs (ie, benzodiazepines, anticonvulsants, heavily anticholinergic agents) should be tapered to prevent withdrawal symptoms. Discontinuing other drugs that interact with necessary drugs, thus increasing the serum levels of the latter drugs, can precipitate problems. Polypharmacy usually occurs over time, and correcting it may take weeks to months.

Pitfall #9: Forgetting Care Continuity

Once patients' polypharmacy issues are resolved, pharmacists need to evaluate them periodically in case unnecessary or inappropriate drugs "sneak back" onto the profile. Patients often forget why they stopped taking a drug and start using it again. Pharmacists have to be tenacious and vigilant.

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. Views expressed in this article are those of the author and not those of any government agency.

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