Polypharmacy

Polypharmacy is the use of four or more medications by a patient, generally adults aged over 65 years. Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes. About 21% of adults with intellectual disability are also exposed to polypharmacy. Polypharmacy is not always bad, but it is bad in many instances, 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. Polypharmacy is often associated with a decreased quality of life, including decreased mobility and cognition.

Whether or not the advantages of polypharmacy (over monotherapy) outweigh the disadvantages or risks depends upon the particular combination and diagnosis involved in any given case. The use of multiple drugs, even in fairly straightforward illnesses, is not an indicator of poor treatment and is not necessarily overmedication. A perfectly legitimate treatment regimen could include, for example, the following: a statin, an ACE inhibitor, a beta-blocker, aspirin, paracetamol and an antidepressant in the first year after a myocardial infarction. 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 physician. 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 interventionism.

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