Trending Clinical Topic: Polypharmacy

Ryan Syrek


September 09, 2022

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Polypharmacy, or the use of multiple medications daily, is on the rise and is associated with various health risks (see Infographic below). Recent studies have examined the benefits of interventions to reduce polypharmacy as well as conditions that tend to be associated with the use of various drugs. Emerging concerns and related findings resulted in this week's top trending clinical topic.

A new review found that strategies designed to curb polypharmacy appear to reduce potentially inappropriate prescribing and significantly improve medication adherence. In their analysis, investigators examined five systematic reviews on interventions published between 2014 and 2019. The mean number of medications taken daily ranged from 5.7 to 9.4. In all five reviews, polypharmacy interventions produced statistically significant reductions in problematic prescribing and improved patient adherence. Two reviews also found reduced healthcare resource usage and expenditures. However, none of the five reported any significant benefits of polytherapy interventions in terms of quality-of-life outcomes or significant differences in adverse drug event outcomes.

Certain conditions result in polypharmacy more than others, and certain populations with those conditions are even more likely to be taking multiple drugs daily. A recent study found that patients aged 65 years or older with HIV take significantly more non–antiretroviral therapy (non-ART) medications compared with patients with HIV who are aged 50-64 years. What's more, in a sample of more than 900 patients with HIV, about 60% were taking at least one potentially inappropriate medication (PIM). Researchers obtained medication reconciliation data for 951 persons with HIV aged 50 or older. The mean number of non-ART medications was 6.7. Patients aged 65 years or older were taking significantly more non-ART medications than were patients aged 50-64 (8.4 vs 6.3; P < .001). The mean number of PIMs per patient was 1.6. Patients living with diagnosed HIV infection for longer than 10 years had a higher risk for PIMs (1.6 PIMs) than those with shorter duration (1.4 PIMs; P = .06).

Multiple sclerosis (MS) is another condition where polypharmacy is a concern. A recent study found that out of 627 patients with MS who took an average of 5.3 drugs each, about 1 in 25 faced a potentially severe interaction, and nearly two thirds had at least one potentially risky interaction. The German study found that 77% of all drug interactions were between prescription drugs; 19% were between prescription drugs and over-the-counter medications; and 4% were between OTC drugs. This underscores the importance of asking about everything that a patient is taking, including herbal supplements, because nearly 60% of people aged 20 years or older take them. One quarter of people older than 60 years take at least four supplements.

Pain control is another area of concern regarding polypharmacy. Back pain, specifically spine-related pain in older patients, is a common cause of over-the-counter and prescription drug use. A recent study found that some medications are safer and more effective than others. Investigators assessed the drugs used for this indication in older adults by reviewing 138 double-blind, placebo-controlled trials. Among the key findings: Acetaminophen has a favorable safety profile for spine-related pain but nonsteroidal anti-inflammatory drugs (NSAIDs) have greater efficacy. However, NSAIDs should be used in lower doses in the short-term, with gastrointestinal precaution, researchers noted. Corticosteroids have the least evidence in support. In terms of muscle relaxants, most evidence favors tizanidine and baclofen. Other findings include:

  • Older tricyclic antidepressants should typically be avoided in older adults because of their side effects; however, nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses.

  • Newer antidepressants, particularly the selective serotonin-norepinephrine reuptake inhibitor duloxetine, have a better safety profile and good efficacy for spine-related nerve pain.

  • Traditional opioids are typically avoided in the treatment of spine-related pain in older adults, owing to their associated risks.

Older adults are at increased risk for polypharmacy, but they are far from the only ones affected. As evidence continues to increase about the dangers of multidrug use so does interest in appropriate interventions. New findings on both resulted in this week's top trending clinical topic.

Use Medscape's Drug Interaction Checker to help avoid significant interactions.


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