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Polypharmacy Guidelines and Strategies: What Does the Literature Say?

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Over the past few decades, there has been a significant increase in the number of patients taking multiple medications. In other words, we've witnessed a rapid rise in polypharmacy — a concept frequently further defined as the routine use of five or more medications. With this growth has come increased attention on polypharmacy, both its risks and value, and an understanding about the importance of polypharmacy management. In fact, effective polypharmacy management is now recognized as one of the most critical components of ensuring safe medication practices — so much so that the World Health Organization included polypharmacy as one of the three key action areas for its "Medication Without Harm" global patient safety challenge.

All these developments further support the need for healthcare organizations to develop approaches to polypharmacy management. This includes identifying those polypharmacy guidelines and strategies that will help guide decision-making concerning policies and procedures.

Let's take a look at a selection of literature offering recommendations and guidance concerning polypharmacy guidelines and strategies.

Pharmacy Guidelines and Strategies for Older Adults

From Clinical Cardiology: "The impact of polypharmacy in older adults can range from reduced quality of life to serious adverse drug events. Most would agree that striking a balance between over‐ and under‐treatment is important, yet doing it effectively is challenging due to the lack of clear guidance and insufficient clinical experience. When assessing whether or not to deprescribe, decisions should be individualized with an emphasis on shared decision‐making with the patient and family, if at all possible. Each time a provider comes in contact with an older adult is an opportunity to review current medications and assess the risk and benefit of each therapy."

From UpToDate: "A balance is required between over- and under-prescribing. Multiple medications are often required to manage clinically complex older adults. … A more systematic approach is required to guide the tailoring of medication regimens to the needs of individuals. One important principle is to match the medication regimen to the patient's condition and goals of care. This includes a careful consideration of the medications that should be discontinued or substituted.

"It is particularly important to reconsider medication appropriateness late in life. A model for appropriate prescribing for patients late in life has been proposed. The process considers the patients' remaining life expectancy and the goals of care in reviewing the need for existing medications and in making new prescribing decisions."

From BMC Family Practice: "Physicians should especially pay attention to their frail, obese patients that have > 8 diagnoses, check whether all medications are necessary, evidence based and appropriate, and whether there are relevant interactions. To do so, [physicians] should perform medication reviews for their patients with excessive polypharmacy on a regular basis to optimize these patients' medication."

From U.S. Pharmacist: "… healthcare providers must evaluate each drug and balance its potential adverse effects against its potential benefits. Advances in information technologies such as electronic prescribing, electronic medical records, and electronic laboratory results, will help prevent adverse drug effects and interactions."

Pharmacy Guidelines and Strategies for Diabetes

From BMJ Open: "… patients with diabetes and polypharmacy may benefit from multidisciplinary collaborative care model that involves pharmacist follow-up for the patients to assess the medication use and minimize polypharmacy. In an open-label, parallel-arm, randomized, controlled study, collaborative care has been associated with improvement in the management of diabetes and reduction the healthcare cost. Pharmacists can help other healthcare providers in detecting polypharmacy [and] drug interactions and in providing recommendations for simplified medication regimens and minimizing medications to positively impact health outcomes of diabetes care."

From American Nurse: "Although glycemic targets for type 2 diabetes are well established, intensive management can lead to adverse outcomes in older adults. For adults with limited life expectancy or severe comorbid illness such as frailty or dementia, aiming for a glycated hemoglobin of < 8.5% is reasonable. For older adults at high risk for hypoglycemia, or for whom hypoglycemia would be detrimental, choosing agents unlikely to promote hypoglycemia is warranted. In some situations, deintensifying or deprescribing therapy in older adults is necessary. In addition to deintensifying regimens, choosing those that are less likely to cause adverse reactions is important.

Polypharmacy Guidelines and Strategies for Cardiovascular Diseases

From the Journal of the American College of Cardiology: "The deprescribing process can be initiated anywhere or by anyone on the healthcare team. Building efficient communication lines between and within teams is the key to successful comanagement of cardiovascular and noncardiovascular medications. For example, if the cardiologist identifies a high-risk or overtly harmful noncardiovascular medication, then the cardiologist can: 1) inform the primary care clinician and the patient to ensure that concerns are raised with the primary care clinician; or 2) the cardiologist can stop or change the medication and communicate this to the patient and primary care clinician (or another prescriber). In either case, direct communication between all involved is paramount."

From Medscape: "To prevent and resolve nonadherence and polypharmacy in patients with heart failure, clinicians should utilize available resources from their own societies as well as patient-education-based programs to develop a shared decision-making, multidisciplinary approach — one that includes dedicated time to identify specific values and preferences of the patient, as well as barriers to medication adherence."

Polypharmacy Guidelines and Strategies for Pharmacists

From U.S. Pharmacist: Polypharmacy, especially in the elderly, can be addressed through several strategies. Pharmacists need to identify drug-related problems, prioritize them, reduce pill burden, eliminate unnecessary medication usage, and monitor for adverse drug-withdrawal events. Pharmacists can optimize medication therapy and improve therapeutic outcomes for patients through medication therapy management (MTM)."

From BMC Geriatrics: "Community pharmacists are well placed to ask simple questions that identify high-priority patients for pharmaceutical intervention and a medication review. In a context of polypharmacy, the often frail older people attending community pharmacies frequently have difficulty in managing, storing, preparing and administering their medications."

From Aging Medicine: "The clinical pharmacist has a major role to play in selecting the best interventions needed to enhance suitable polypharmacy and consequently managing problems associated with polypharmacy properly to accomplish better clinical results for patients."

From the American Journal of Health-System Pharmacy: "Polypharmacy is common among patients with chronic obstructive pulmonary disease (COPD), with up to 50% of all hospitalized older patients and about 14% of those with COPD receiving five or more medications. Additionally, hospitalization for an acute exacerbation of COPD is associated with greater disease severity and an increased risk of adverse drug events (ADEs). ADEs and suboptimal adherence due to polypharmacy are modifiable barriers that significantly contribute to morbidity. Pharmacists play a significant role in preventing ADEs by critically analyzing the medication list and discontinuing (or recommending discontinuation of) medications that do not provide effective disease control or whose use results in ADEs."

Polypharmacy Guidelines and Strategies for Psychologists

From Psychiatric Times: "There is a need for proper clinical titration, sound treatment algorithms, and well-defined protocols to effectively reduce irrational polypharmacy. An important clinical issue is when a patient on multiple drugs presents to a psychiatrist who wants to change the prescriptions to another multiple-drug combination. It is important that certain drugs from the previous prescriptions be retained so that a switch can be made. Tapering medication must be done at a gradual rate while closely monitoring for withdrawal/rebounding symptoms. When changing a medication, it is wise to switch the medication with one that has a similar half-life to enhance continuity of action."

Deprescribing Polypharmacy Guidelines

As was mentioned in a few of the polypharmacy guidelines and strategies discussed above, deprescribing should be considered as a component of your organization's polypharmacy management plan. Deprescribing is the "… planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm." There have been several evidence-based deprescribing guidelines developed, and more are in the works.

To learn about eight of these deprescribing guidelines as well as additional resources your organization can use to help safely decrease inappropriate polypharmacy and support sound deprescribing efforts, click here.

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