How to approach polypharmacy in patients taking multiple medications?

Systematic Approach to Managing Polypharmacy

A systematic, consultative approach that identifies high-risk medications and drug therapy problems is essential to reduce polypharmacy-related morbidity, mortality, and decreased quality of life. 1

Definition and Impact of Polypharmacy

• Polypharmacy is commonly defined as the concurrent use of 5 or more medications, including over-the-counter, prescription, traditional, and complementary medicines 1
• Polypharmacy is associated with serious adverse outcomes including:
  • Drug-drug interactions and drug toxicity 1
  • Falls with injury and increased mortality 1
  • Delirium and cognitive impairment 1
  • Medication nonadherence 1
  • Increased hospitalizations and healthcare costs 1
  • Functional decline 1

Step-by-Step Management Algorithm

1. Medication Reconciliation

• Create an accurate medication list at every visit, including all prescriptions, over-the-counter medications, and supplements 1
• Identify discontinued, missing, or incorrectly taken medications 1
• Document dosage, frequency, and indication for each medication 1

2. Adherence Assessment

• Use validated tools like the Morisky Medication Adherence Scale to identify adherence barriers 1
• Review pill boxes, medication bottles, and fill dates 1
• Identify complex regimens (3-4 times daily dosing) that may contribute to nonadherence 1
• Address affordability issues that may lead to missed medications 1

3. Drug-Drug Interaction Screening

• Use interaction databases to identify high-risk combinations 1
• Pay particular attention to:
  • QT prolongation risks 1
  • Anticoagulant interactions and bleeding risk 1
  • Serotonin syndrome potential 1
  • Medications requiring cytochrome P450 metabolism 1

4. Drug-Disease Interaction Screening

• Identify medications that may worsen existing conditions 1
• Common problematic combinations include:
  • NSAIDs in heart failure, chronic kidney disease, or hypertension 1
  • Sulfonylureas in chronic kidney disease 1
  • Anticholinergics in cognitive impairment 1

5. Identify Overtreatment

• Look for duplicate therapies or medications with additive side effects 1
• Assess for prescribing cascades (medications prescribed to treat side effects of other medications) 1
• Consider whether all medications still align with current treatment goals 1

6. Screen for High-Risk Medications

• Use validated tools to identify potentially inappropriate medications:
  • American Geriatrics Society Beers Criteria for patients ≥65 years 1
  • STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions) 1
  • START (Screening Tool to Alert to Right Treatment) 1
  • Medication Appropriateness Index (MAI) 1
• Pay special attention to high-risk drug classes:
  • Opioids, benzodiazepines, and other sedatives 1
  • Anticholinergics 1
  • Hypoglycemic agents 1
  • Antihypertensives and diuretics 1

7. Identify Undertreated Conditions

• Assess for indicated medications that may have been overlooked 1
• Examples include statins or antiplatelet therapy in appropriate cardiovascular patients 1

8. Monitor for Efficacy and Safety

• Ensure appropriate monitoring for each medication (e.g., glucose monitoring with insulin, INR with warfarin) 1
• Regularly assess kidney and liver function for medications requiring dose adjustments 1

Implementing Deprescribing

• Deprescribing is the process of reducing drug dose, weaning off, discontinuing, or switching to safer alternatives when potential harm outweighs benefit 1
• Best practices for deprescribing include:
  • Education about risks for patients and families 1
  • Agreement by patients, families, and care teams 1
  • Framing within patient's goals of care (comfort vs. longevity) 1
  • Gradual tapering of high-risk medications like opioids and benzodiazepines 1
  • Regular follow-up to monitor for withdrawal symptoms or disease recurrence 2

Special Considerations

Elderly Patients

• Aging-related changes in pharmacokinetics and pharmacodynamics increase sensitivity to medications 1
• Adjust doses based on declining kidney function using laboratory-reported clearance estimates 1
• Consider functional and cognitive status, not just chronological age, when making medication decisions 1

Transitions of Care

• Medication reconciliation is critical during care transitions (hospital admission/discharge, new care settings) 1
• Communication between providers is essential to prevent inappropriate prescriptions 1

Team-Based Approach

• Utilize clinical pharmacists for medication reviews when available 1
• Coordinate care among multiple prescribers to prevent duplication 1
• Consider computerized alerts and decision support tools 1

Common Pitfalls to Avoid

• Focusing only on the number of medications rather than appropriateness 1
• Failing to consider patient preferences and treatment goals 1
• Abruptly discontinuing medications without proper tapering 1
• Overlooking non-prescription medications and supplements 1
• Treating medication side effects with additional medications (prescribing cascade) 1
• Not adjusting doses for declining kidney function 1
• Lack of communication between multiple prescribers 1

By systematically addressing polypharmacy using this approach, clinicians can significantly reduce medication-related harm while maintaining or improving quality of life for patients with complex medication regimens.