6 Questions Pharmacists Can Ask to Prevent Polypharmacy

Unnecessary or inappropriate use of medications is a costly and potentially deadly problem.

Because current health care practices focus primarily on diagnosing and prescribing drugs, the need to taper, reduce, or discontinue inappropriate therapy receives relatively little attention. In fact, few clinical guidelines cover drug deprescribing, and this lack of evidence-based direction contributes to prescribers’ hesitancy or reluctance to touch treatment regimens that may have originated from a different practice setting.

The resultant polypharmacy may disproportionately affect older patients, who take 5 medications by age 65 and 7 by age 85 on average—often to treat several different chronic conditions.

Failure to deprescribe medications contributing to adverse side effects can have serious consequences, explained Thomas R. Clark, RPh, MHS, CGP, executive director of the Commission for Certification in Geriatric Pharmacy, in a previous interview with Pharmacy Times.

As a general rule of thumb, “the more medication a patient takes, the greater the risk of adverse drug reactions and interactions,” Dr. Clark said.

Regardless of age, pharmacists should ask the following questions during medication reconciliation to prevent polypharmacy.

1. Are the patient’s medications being used for their FDA-approved indications?

One easy way to eliminate an unnecessary medication is to question a prescription for an off-label use.

For example, oral naltrexone is approved for the treatment of alcohol and opioid dependence, but preliminary evidence suggests it could be beneficial in the treatment of impulse control disorders such as kleptomania, compulsive gambling, or compulsive hair pulling. Other off-label uses include preventing self-injurious behavior and treating fibromyalgia. However, pharmacists should know that current data aren’t necessarily strong enough to warrant a prescription for any of these indications.

Pharmacists should make sure to contact the prescriber in these situations because some conditions create complex care needs, thereby rendering polypharmacy legitimate.

2. Will any of the patient’s medications interact with another?

It’s important for pharmacists and prescribers to make an effort to reduce the number of medications a patient takes in order to minimize the risk of drug interactions, which can range from mild to life-threatening.

CYP3A4 substrates, for example, have been shown to metabolize and thus reduce the effects of about half of all drugs on the market. This type of drug interaction may be more frequent than commonly realized, since a reduced drug effect may be erroneously attributed to lack of patient response.

Additionally, anticholinergics were identified in the 2015 Updated Beers Criteria because taking more than 1 medication in this class, which is also known as anticholinergic burden, has been linked to cognitive decline.

Click here for a detailed list of 10 drug interactions every pharmacist should know.

http://www.pharmacytimes.com/publications/issue/2013/october2013/drug-supplement-interactions-patient-awareness-is-key3. Is the patient taking supplements?

The risk for polypharmacy extends beyond prescription medications.

Many patients believe nutritional supplements lack adverse effects, and so the consequences of potential drug-supplement interactions aren’t necessarily understood.

The most important step pharmacists and other health care providers can take to try and limit the number of adverse drug-supplement interactions is to ask patients about their medication regimens. Studies have shown that patients don’t normally disclose their use of complementary and alternative medicines without being asked about it directly.

Examples of vitamins with potential for serious interactions include vitamins A and E, which increase the effects of anticoagulation and should therefore be closely monitored when taking warfarin. Additionally, magnesium can decrease antibiotic absorption and should thus be dosed separately by 2 hours before or 6 hours after taking an antibiotic.

4. Do the side effects of the patient’s medications outweigh their benefits?

For some patients, the side effects associated with a particular drug (or polypharmacy in general) may not outweigh the intended benefits.

One study from Kaiser Permanente found that men who take multiple medications are more likely to experience severe erectile dysfunction (ED). The drugs most commonly associated with ED are antihypertensives, such as beta-blockers, thiazides, and clonidine; psychogenic medications, such as selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium, and monoamine oxidase inhibitors; and any medications that interfere with testosterone.

If you can stomach it, click here for a list of disgusting potential side effects of certain medications.

5. Is one medication being used to treat the side effect of another?

Older adults often fall victim to the “prescribing cascade” that occurs when “new symptoms end up being treated with a new drug instead of discontinuing or changing the offending drug that is causing the symptom,” Dr. Clark explained.

If a patient is receiving a pharmacologic agent to treat medication-induced nausea, for example, pharmacists can offer a few simple reminders that may reduce nausea and allow the patient to take one less medication. Unless a drug is meant to be taken on an empty stomach, patients can be advised to take their medications with food. The time of day a medication is taken may also be an important consideration when preventing nausea caused by dizziness.

Meanwhile, adjunctive polypharmacy is very common in psychiatric medicine, as trazodone is often prescribed to counteract the insomnia produced by bupropion.

6. Can any of the patient’s conditions be treated without medication?

Sometimes, a prescription drug isn’t the only option for treating a certain ailment.

For instance, there are a number of nonpharmacologic self-treatment options for heartburn that patients can try. Elevating the head of the bed, losing weight, and avoiding late-night eating are all evidence-based measures that support improved clinical outcomes.

For allergies, patients can try nonpharmacologic strategies for reducing allergen exposure, such as minimizing exposure to pollen or mold by keeping windows and doors closed during pollen season and limiting time spent outdoors during peak times, in the place of antihistamines or inhaled corticosteroids.