What is the best approach to manage polypharmacy in an elderly patient with gout, hypertension, benign prostatic hyperplasia (BPH), hyperlipidemia, and chronic obstructive pulmonary disease (COPD) or asthma?

Managing Polypharmacy in Elderly Patients with Multiple Comorbidities

Implement systematic medication review at every visit using explicit criteria (Beers or STOPP/START tools) to identify and deprescribe high-risk medications, prioritizing those causing immediate harm or lacking indication, while simplifying regimens to once or twice daily dosing. 1, 2

Step 1: Complete Medication Reconciliation

• Create an accurate list of ALL medications at every visit, including prescriptions, over-the-counter drugs, supplements, herbal remedies, and vitamins 3, 2
• Review pill boxes, medication bottles, and pharmacy fill dates to identify discontinued, missing, or incorrectly taken medications 2
• Assess adherence using the Morisky Medication Adherence Scale to identify barriers such as complex dosing schedules, cost issues, and side effects 1, 2

Step 2: Screen for Drug-Related Problems

Identify High-Risk Medications Using Explicit Criteria

• Apply Beers Criteria or STOPP/START tools to flag potentially inappropriate medications in patients ≥65 years 3, 1, 4
• Priority targets for deprescribing include:
  • Anticholinergic medications (diphenhydramine, cyclobenzaprine, oxybutynin) causing cognitive decline, constipation, urinary retention, and falls 3
  • Sulfonylureas and short-acting insulin causing hypoglycemia and emergency department visits 3
  • Benzodiazepines and sedatives increasing fall risk and cognitive impairment 1
  • NSAIDs worsening hypertension, heart failure, chronic kidney disease, or precipitating gout attacks 3, 2

Screen for Drug-Drug and Drug-Disease Interactions

• Use interaction databases to identify high-risk combinations, particularly QT prolongation risks, anticoagulant interactions, and cytochrome P450 metabolism issues 2
• For your patient's specific conditions, avoid:
  • NSAIDs in hypertension, BPH (may worsen urinary symptoms), and potential gout exacerbation 3, 2
  • Beta-blockers in COPD/asthma (may cause bronchospasm) 3
  • Thiazide diuretics in gout and hyperlipidemia 3
  • Anticholinergics in BPH (may cause urinary retention) 3

Step 3: Assess for Prescribing Cascades

• Determine if any new symptom represents an adverse drug reaction rather than a new disease requiring additional medication 3, 2
• Common cascades to identify:
  • NSAIDs causing hypertension, then adding antihypertensives 3
  • Diuretics causing urinary frequency, then adding anticholinergics for overactive bladder 3
  • Antihypertensives causing dizziness, then adding meclizine (anticholinergic) 3

Step 4: Implement Deprescribing Protocol

Prioritize Medications for Discontinuation

Deprescribe in this order: 1, 2

1. Medications causing immediate harm (e.g., anticholinergics causing delirium, NSAIDs causing acute kidney injury)
2. High-risk medications without clear indication (e.g., proton pump inhibitors without documented need, unnecessary supplements)
3. Medications where time-to-benefit exceeds life expectancy (e.g., statins for primary prevention in limited life expectancy)

Specific Deprescribing Strategies for Your Patient

For Gout Management:

• Reduce colchicine dose if creatinine clearance <10 mL/min to prevent toxicity 3
• Avoid thiazide diuretics for hypertension; use alternative antihypertensives 3

For Hypertension:

• Simplify to once-daily dosing with long-acting agents (avoid immediate-release nifedipine) 3, 1
• Monitor for orthostatic hypotension and adjust doses based on declining renal function 3, 1

For BPH:

• Eliminate all anticholinergic medications that worsen urinary retention 3
• Consider alpha-blockers but monitor for orthostatic hypotension and falls 3

For COPD/Asthma:

• Avoid beta-blockers entirely (including for hypertension) 3
• Use cardioselective agents only if absolutely necessary for cardiac indications 3

For Hyperlipidemia:

• Discontinue statins if estimated life expectancy is shorter than time-to-benefit (typically 2-5 years for primary prevention) 1
• Reduce statin dose if causing myalgia or lower extremity pain 3

Tapering Protocols for High-Risk Medications

• Benzodiazepines: Reduce dose by 25% every 1-2 weeks, monitoring for withdrawal symptoms 1
• Antipsychotics: Gradual discontinuation with monitoring for behavioral changes 1
• Opioids: Slow taper over weeks to months depending on duration of use 3

Step 5: Simplify and Optimize Remaining Medications

• Consolidate to once or twice daily dosing whenever possible to improve adherence 1
• Adjust doses based on declining kidney function using laboratory-reported creatinine clearance 1, 2
• Specific dose adjustments:
  • Metformin: Avoid if CrCl <30 mL/min (risk of lactic acidosis) 3
  • Digoxin: Maintenance doses <0.125 mg/day in patients ≥75 years 3
  • Loop diuretics: Increase dose if CrCl <30 mL/min due to impaired tubular secretion 3

Step 6: Monitor for Undertreated Conditions

• Use START criteria to identify potentially beneficial medications that are missing 3
• For your patient, ensure appropriate treatment for:
  • Cardiovascular disease (antiplatelet agents if indicated) 3
  • COPD exacerbation prevention (inhaled corticosteroids/long-acting bronchodilators) 3
  • Osteoporosis prevention (vitamin D supplementation) 3

Step 7: Implement Team-Based Monitoring

• Coordinate care among multiple prescribers to prevent duplication and ensure safe medication use 1, 2
• Utilize clinical pharmacists for comprehensive medication reviews when available 1, 2
• Schedule follow-up visits to assess medication effectiveness, adverse effects, and adherence 2
• Increase monitoring frequency during care transitions (hospital discharge, nursing home placement) 2

Critical Pitfalls to Avoid

• Never abruptly discontinue medications without proper tapering, particularly benzodiazepines, opioids, beta-blockers, and clonidine (risk of withdrawal syndrome) 3, 2
• Do not focus solely on medication count; appropriateness matters more than the absolute number 2
• Avoid overlooking non-prescription medications and supplements that contribute to anticholinergic burden, drug interactions, and medication costs 3, 2
• Do not use chronological age alone to determine medication appropriateness; consider functional status, cognitive status, and life expectancy 3, 1
• Beware of aggressive glycemic control (HbA1c <7%) in elderly patients, which increases hypoglycemia risk, dizziness, confusion, and falls 3