Recommendations for Improving Medication Safety by Reducing Inappropriate Polypharmacy

The term “polypharmacy” first appeared in the literature in the 1800’s and was used to describe the use of multiple medications to treat a single condition. Since then, “polypharmacy” has been used to refer to many situations, including getting medications from more than one pharmacy and using more than one medication to treat a single condition. However, the most commonly used definition refers to a situation where a patient is being treated with many—five or more—medications.1,2

Patients of all ages may potentially receive polypharmacy. This is most common in the setting of chronic and/or complicated diseases and includes young children3, adolescent and young adults4 and older adults. According to the US Centers for Disease Control and Prevention, from 2011-2014, among patients age 65 years and over, four out of 10 (40.7%) used five or more different prescription medicines in the past month.5 Between 1988 and 2010 the median number of prescription medications used among adults aged 65 and older doubled from 2 to 4, and the proportion taking ≥5 medications tripled from 12.8% to 39.0%.6 Part of the reason for this is that this subset of the population generally sees more doctors (primary care and specialists) and are more likely to suffer from more than one chronic disease. The consequences of polypharmacy are more common and often more severe in the elderly, as they are more likely to have a number of chronic conditions.7 Change in cognition and mental function can negatively impact patients’ ability to adhere to treatment plans. The physiological changes (e.g., changes in organ function, drug metabolism and excretion), in particular those that are age-related, also impact how drugs affect patients and can place them at higher risk of experiencing harm, particularly in the case of those receiving inappropriate polypharmacy.

The patient safety goal should be to eliminate patient exposure to medications that have an unfavorable balance of benefit to harm when compared to alternative treatment options. As a result, the risk of patient harm from inappropriate polypharmacy can be reduced. However, there are a number of challenges that may need to be addressed to accomplish that goal, including poor communication among clinicians about the intent of the medication and/or when to discontinue or adjust doses; lack of awareness by the healthcare provider of the patient’s current and complete medication regimen, including prescription medications, over-the-counter products, dietary supplements and minerals; lack of awareness that the patient may independently be seeking medications to relieve symptoms or cure a disease; and use of a medication to ameliorate the symptoms caused by another medication which may not be needed.

Recommendations

The National Coordinating Council on Medication Error Reporting and Prevention makes the following recommendations to reduce patient harm and medication errors associated with polypharmacy.

For Providers:

  1. Consider using “polypharmacy” (i.e., a regimen with  5 medications) as a trigger (not a target) for an in-depth therapeutic review for appropriateness. Ideally, every patient’s therapeutic regimen, regardless of its size, should be reviewed for appropriateness with each patient encounter and should be coordinated with all of the patient’s providers.
  2. Use a patient-centered approach that optimizes medication regimen on appropriateness, safety, affordability, ease of use, and patient’s ability and willingness to adhere. To improve meaningful conversations with patients and caregivers, ask the patient “What matters to you?”8
  3. Ensure that each medication prescribed for the patient has a matching diagnosis in the patient’s problem list and fits appropriately into the whole treatment plan.
  4. At a minimum, whenever a medication is added to a patient’s treatment plan, the medication’s potential risks and benefits for the individual patient should be evaluated in context with other medications the patient is taking
  5. Use standardized tools, such as the Beers Criteria9 and STOPP/START Criteria10 for use with older adults, to carefully screen patients for potentially inappropriate medications.
  6. Discontinue medications which have been identified as potentially harmful unless there are no other clinical alternatives and the medication still provides appropriate benefit to the patient. Inform the patients’ other providers of any medication regimen changes.
  7. Ensure medication side effects and toxicities are included in the differential diagnosis of every new symptom until ruled out.
  8. Use a risk versus benefit approach to find the most appropriate therapy given the patient’s values and ability to adhere to the chosen regimen.
  9. To further optimize medication safety, refer patients to a pharmacist for medication therapy management (MTM).
    • If the patient is a Medicare Part D enrollee, inquire if he/she’s Part D plan has already identified him/her as eligible for free Medication Therapy Management services.

For patients, families and caregivers:

  1. Ask if the medication is appropriate for you (the patient) at your age, medical condition, and with your current medication regimen.
  2. Understand what effects (both good and bad) to expect from your medications. Communicate any bad effect from your medications to your providers so your treatment plan can be changed or improved as needed
  3. When a new drug is discussed or prescribed, ask about if any medications should be continued, which should be stopped, and which medication supplies should be thrown away.
  4. Watch for any change in your thinking abilities which may make it difficult to properly take your medications. If your ability to self-manage your medications decreases, identify someone who will be the coordinator of care to track and manage your medications.
  5. Carry your up to date (current) medication list (including doses you are using) with you and present it to each healthcare practitioner at every visit.
  6. Under the direction of your physician or pharmacists, limit your medications to those that will provide you the best outcome. More is not always better.
  7. Consider utilizing only one pharmacy – your “pharmacy home” - so that your pharmacist has access to your complete medication history and current regimen.

RESOURCES

  1. Your Medicine: Be Smart. Be Safe (https://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/tips-and-tools/yourmeds.html). This resource from the Agency for Healthcare Research and Quality provided Information and tools (including a wallet card) to help patients, families, and caregivers to be active members of their healthcare team.
  2. Talk Before You Take (http://www.talkbeforeyoutake.org/). Aimed at reducing adverse drug events and improving medication adherence, this initiative is designed to encourage and improve communications between providers and patients about their medicines. The initiative details 10 questions patients should ask their provider when prescribed a new medication.

REFERENCES

  1. Bushardt RL, Massey EB, et al., Polypharmacy: Misleading, but Manageable. Clin Interv Aging, 2008;3(2):383-389
  2.  Masnoon N, Shakib S, et al., What is polypharmacy? A systematic review o0f definitions.  BMC Geriatr 2017 Oct 10; 17(1):230
  3. Horace AE and F Ahmed. Polypharmacy in pediatric patients and opportunities for pharmacists’ involvement. Integr Pharm Res Pract. 2015; 4: 113–126.
  4. Murphy, C, Fullington, H, Alvarez, C., Lee, S, Betts, A, Haggstrom, D and E. Halm. (2018). 2163 Polypharmacy and patterns of prescription medication use among cancer survivors. Journal of Clinical and Translational Science, 2(S1), 85-86. doi:10.1017/cts.2018.297.
  5. Center for Disease Control and Prevention. Health, United States, 2014 – Individual Charts and Tables. Table 85. Prescription drug use in the past 30 days, by sex, age, race and Hispanic origin: United States, selected years 1988-1994 through 2009-2012. https://www.cdc.gov/nchs/data/hus/2014/085.pdf
  6. Charlesworth CJ, Smit E, et al., Polypharmacy Among Adults Aged 65 and Older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci. 2015 Aug; 70(8):989-995.
  7. Cooper JA, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people: a Cochrane systematic review. BMJ Open. 2015;5:e009235.
  8. Institute for Healthcare Improvement. The Power of Four Words: "What Matters to You?" http://www.ihi.org/Topics/WhatMatters/Pages/default.aspx
  9. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-94.
  10. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015, Mar; 44(2): 213–218.
Adopted: 
March 30, 2021