Polypharmacy and the brown bag

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Polypharmacy

Use of five or more medications daily

Not to be confused with combination drug.

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions.^[1][2] The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time.^[1][3][4] Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older.^[5][6] In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population.^[7][8] In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects.^[9] Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.^[9]

The prevalence of polypharmacy is estimated to be between 10% and 90% depending on the definition used, the age group studied, and the geographic location.^[10] Polypharmacy continues to grow in importance because of aging populations. Many countries are experiencing a fast growth of the older population, 65 years and older.^[11][12][13] This growth is a result of the baby-boomer generation getting older and an increased life expectancy as a result of ongoing improvement in health care services worldwide.^[14][15] About 21% of adults with intellectual disability are also exposed to polypharmacy.^[16] The level of polypharmacy has been increasing in the past decades. Research in the USA shows that the percentage of patients greater than 65 years-old using more than 5 medications increased from 24% to 39% between 1999 and 2012.^[17] Similarly, research in the UK found that the number of older people taking 5 plus medication had quadrupled from 12% to nearly 50% between 1994 and 2011.^[18]

Polypharmacy is not necessarily ill-advised, but in many instances can lead to negative outcomes or poor treatment effectiveness, often being more harmful than helpful or presenting too much risk for too little benefit. Therefore, health professionals consider it a situation that requires monitoring and review to validate whether all of the medications are still necessary. Concerns about polypharmacy include increased adverse drug reactions, drug interactions, prescribing cascade, and higher costs.^[19] A prescribing cascade occurs when a person is prescribed a drug and experiences an adverse drug effect that is misinterpreted as a new medical condition, so the patient is prescribed another drug.^[20] Polypharmacy also increases the burden of medication taking particularly in older people and is associated with medication non-adherence.^[21]

Polypharmacy is often associated with a decreased quality of life, including decreased mobility and cognition.^[22] Patient factors that influence the number of medications a patient is prescribed include a high number of chronic conditions requiring a complex drug regimen. Other systemic factors that impact the number of medications a patient is prescribed include a patient having multiple prescribers and multiple pharmacies that may not communicate.

Whether or not the advantages of polypharmacy (over taking single medications or monotherapy) outweigh the disadvantages or risks depends upon the particular combination and diagnosis involved in any given case.^[23] The use of multiple drugs, even in fairly straightforward illnesses, is not an indicator of poor treatment and is not necessarily overmedication. Moreover, it is well accepted in pharmacology that it is impossible to accurately predict the side effects or clinical effects of a combination of drugs without studying that particular combination of drugs in test subjects. Knowledge of the pharmacologic profiles of the individual drugs in question does not assure accurate prediction of the side effects of combinations of those drugs; and effects also vary among individuals because of genome-specific pharmacokinetics. Therefore, deciding whether and how to reduce a list of medications (deprescribe) is often not simple and requires the experience and judgment of a practicing clinician, as the clinician must weigh the pros and cons of keeping the patient on the medication. However, such thoughtful and wise review is an ideal that too often does not happen, owing to problems such as poorly handled care transitions (poor continuity of care, usually because of siloed information), overworked physicians and other clinical staff, and interventionism.

1. ^ ^{a b} Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE (October 2017). "What is polypharmacy? A systematic review of definitions". BMC Geriatrics. 17 (1): 230. doi:10.1186/s12877-017-0621-2. PMC 5635569. PMID 29017448.
2. ^ Lee GB, Etherton-Beer C, Hosking SM, Pasco JA, Page AT (January 2022). "The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review". Therapeutic Advances in Drug Safety. 13: 20420986221100117. doi:10.1177/20420986221100117. PMC 9260603. PMID 35814333.
3. ^ Taghy N, Cambon L, Cohen JM, Dussart C (2020). "Failure to Reach a Consensus in Polypharmacy Definition: An Obstacle to Measuring Risks and Impacts-Results of a Literature Review". Therapeutics and Clinical Risk Management. 16: 57–73. doi:10.2147/TCRM.S214187. PMC 7023902. PMID 32103967.
4. ^ Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S (June 2017). "Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy". Pharmacology Research & Perspectives. 5 (3): e00321. doi:10.1002/prp2.321. PMC 5464348. PMID 28603638.
5. ^ "Multiple long-term conditions (multimorbidity): making sense of the evidence". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2021-03-30. doi:10.3310/collection_45881. S2CID 243406561.
6. ^ Schneider J, Algharably EA, Budnick A, Wenzel A, Dräger D, Kreutz R (2021-06-08). "High Prevalence of Multimorbidity and Polypharmacy in Elderly Patients With Chronic Pain Receiving Home Care are Associated With Multiple Medication-Related Problems". Frontiers in Pharmacology. 12: 686990. doi:10.3389/fphar.2021.686990. PMC 8217758. PMID 34168565.
7. ^ "polypharmacy". Oxford English Dictionary. 2022. The use of multiple drugs or medicines for several concurrent disorders (now esp. by elderly patients), often with the suggestion of indiscriminate, unscientific, or excessive prescription.
8. ^ "A Glossary of Terms for Community Health Care and Services for Older Persons" (PDF). World Health Organization. 2004. p. 45. Retrieved September 6, 2022. 1 The administration of many drugs at the same time. 2 The administration of an excessive number of drugs.
9. ^ ^{a b} Cole, Judith A; Gonçalves-Bradley, Daniela C; Alqahtani, Mubarak; Barry, Heather E; Cadogan, Cathal; Rankin, Audrey; Patterson, Susan M; Kerse, Ngaire; Cardwell, Chris R; Ryan, Cristin; Hughes, Carmel (2023-10-11). Cochrane Effective Practice and Organisation of Care Group (ed.). "Interventions to improve the appropriate use of polypharmacy for older people". Cochrane Database of Systematic Reviews. 2023 (10): CD008165. doi:10.1002/14651858.CD008165.pub5. PMC 10565901. PMID 37818791.
10. ^ Khezrian M, McNeil CJ, Murray AD, Myint PK (2020). "An overview of prevalence, determinants and health outcomes of polypharmacy". Therapeutic Advances in Drug Safety. 11: 2042098620933741. doi:10.1177/2042098620933741. PMC 7294476. PMID 32587680.
11. ^ Cruz LP, Miranda PM, Vedana KG, Miasso AI (2011). "Medication therapy: adherence, knowledge and difficulties of elderly people from bipolar disorder". Revista Latino-Americana de Enfermagem. 19 (4): 944–952. doi:10.1590/S0104-11692011000400013. PMID 21876947.
12. ^ Gellad WF, Grenard JL, Marcum ZA (February 2011). "A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity". The American Journal of Geriatric Pharmacotherapy. 9 (1): 11–23. doi:10.1016/j.amjopharm.2011.02.004. PMC 3084587. PMID 21459305.
13. ^ Page AT, Falster MO, Litchfield M, Pearson SA, Etherton-Beer C (July 2019). "Polypharmacy among older Australians, 2006-2017: a population-based study". The Medical Journal of Australia. 211 (2): 71–75. doi:10.5694/mja2.50244. PMID 31219179.
14. ^ Cline CM, Björck-Linné AK, Israelsson BY, Willenheimer RB, Erhardt LR (June 1999). "Non-compliance and knowledge of prescribed medication in elderly patients with heart failure". European Journal of Heart Failure. 1 (2): 145–149. doi:10.1016/S1388-9842(99)00014-8. PMID 10937924. S2CID 32043403.
15. ^ Yasein NA, Barghouti FF, Irshaid YM, Suleiman AA (March 2013). "Discrepancies between elderly patient's self-reported and prescribed medications: a social investigation". Scandinavian Journal of Caring Sciences. 27 (1): 131–138. doi:10.1111/j.1471-6712.2012.01012.x. PMID 22616831.
16. ^ Haider SI, Ansari Z, Vaughan L, Matters H, Emerson E (November 2014). "Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability". Research in Developmental Disabilities. 35 (11): 3071–3080. doi:10.1016/j.ridd.2014.07.060. PMID 25129201.
17. ^ Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL (November 2015). "Trends in Prescription Drug Use Among Adults in the United States From 1999-2012". JAMA. 314 (17): 1818–1831. doi:10.1001/jama.2015.13766. PMC 4752169. PMID 26529160.
18. ^ Gao L, Maidment I, Matthews FE, Robinson L, Brayne C (March 2018). "Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II". Age and Ageing. 47 (2): 220–225. doi:10.1093/ageing/afx158. PMC 6037294. PMID 29036509.
19. ^ Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J (January 2009). "The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people". Journal of the American Geriatrics Society. 57 (1): 62–69. doi:10.1111/j.1532-5415.2008.02040.x. PMID 19054196. S2CID 205703844.
20. ^ Ponte ML, Wachs L, Wachs A, Serra HA (2017). "Prescribing cascade. A proposed new way to evaluate it". Medicina. 77 (1): 13–16. PMID 28140305.
21. ^ Maidment ID, Lawson S, Wong G, Booth A, Watson A, McKeown J, et al. (June 2020). "Medication management in older people: the MEMORABLE realist synthesis". Health Services and Delivery Research. 8 (26): 1–128. doi:10.3310/hsdr08260. PMID 32579319. S2CID 225671789.
22. ^ "Polypharmacy in Elderly Patients" (PDF). Vumc.nl. Archived from the original (PDF) on 22 January 2016. Retrieved 16 January 2015.
23. ^ Tamminga CA (July 2011). "When is polypharmacy an advantage?". The American Journal of Psychiatry. 168 (7): 663. doi:10.1176/appi.ajp.2011.11050695. PMID 21724668.

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