Polypharmacy is a word that creeps into the vocabulary of many patients with a chronic illness, particularly those who have more than one chronic condition. There are two general uses of the term. The use patients are apt to know is that polypharmacy refers to the use of multiple medications. If you have a chronic condition, for example, you may be asked to take multiple drugs to maintain your health and to manage acute flare-ups of the illness. If you have multiple conditions, such as both diabetes and high blood pressure, it would refer to your taking drugs for both conditions.
The second of the term polypharmacy is that it refers to "many drugs" and to problems that can occur when a patient is taking more medications than one. Use of the term in this manner also includes the inappropriate use of multiple medications rather than the rational use of drugs taken for more than one illness. Polypharmacy can be used to refer to bottle proliferation, or to excessive number, high frequency, multiple doses, and unnecessary use of medications by a given patient. The paper will describe polypharmacy in light of the dual general meanings of the word.
Patients and polypharmacy
You know the meaning of polypharmacy if you take multiple drugs. As noted, you may take them for multiple conditions or for treating the same condition. If you have asthma, for example, you may be told to use one medication to control your condition and a second drug to manage any attack that occurs. The two types of drugs, in this case, are totally different: you cannot take the controller drug to manage an asthma episode nor can you take the quick relief drug on a regular basis to manage your condition. While patients likely understand one meaning of the polypharmacy, they often fail to understand the other use of the term. Whether the difference is not thoroughly explained to them or that they know what to do but just don’t do so is unknown. Certainly, the taking of more than one drug makes any drug regimen more complicated. Taking several drugs to treat a number of illnesses, usually referred to as treating comorbid conditions, really makes the matter complex.
Managing polypharmacy can be a difficult task to many patients. To help you control the taking of medications, especially multiple drugs, a number of common suggestions have been offered over the year. These can be called the do’s and don’ts of taking drugs. At first, these were thought of as ways to improve medication compliance, but they have been found to be equally important in helping people like you manage multiple drugs.
Do’s
1. When a medication is prescribed for you, ask why it you are being asked to take the drug and what it is intended to do. Is it going to replace another drug or is it a new drug you are being asked to take? The same question should be asked if the dosage level of a medication you are taking is being increased or decreased. Why is this happening? You also want to know the cost of the drug. If it is too expensive for you or not covered by your health insurance? Is there an alternative drug, perhaps generic, you can take? It is the patient being asked to take a medication, not the health care provider. If you understand why a drug has been prescribed for you, it is likely to be more effective (think suggestion as occurs with the placebo effect). You are also more likely to adhere to your medication instructions.
2. For any medication prescribed for you, it is important that you understand when and how to take the medicine. Should you take it with food or on an empty stomach? Is it to be taken in the morning or at bedtime? Should you take it with something else such as dairy products or other foods? You should know all these answers when receiving a prescription. If a drug is taken via an inhaler or injected, you must thoroughly understand how to use the apparatus before leaving your health care provider’s office. If you don’t know how to use the equipment, the likelihood is that it will not deliver on what it is designed to do.
3. It is important that you take your medications exactly as directed by your health care provider. Either he or she can tell you what to do if you miss a dose, but you can also read what to do in the instructions accompanying medications. Don’t double up doses unless you are told to do so.
4. You should keep a list of all your medications and their dosages handy for you. Add in any vitamins, minerals, or herbal products you may be using. These can be reviewed during each visit, but it is unlikely that you need to do so. You should, however, do it on a regular basis, especially if you have started taking another prescribed drug or the latest herbal product you’ve heard will “cure” your chronic illness. (This is the ol’ “Well, it sure worked for Mabel and she has exactly what you have!”adage.) Believe me when I say that if there was a chance for better and safer products for your condition, someone would be working to develop and test it.
5. It is recommended that you always use the same pharmacy for all of your prescription medications. Most modern pharmacies today have computer systems that will alert the pharmacist to any possible drug interactions. However, you cannot depend upon others to discover any potential drug interactions; you must spend a few moments and review the inserts that come with a drug. If you drink alcohol, ask your health care provider about the safety of drinking alcohol while taking medication(s).
6. Read labels on medications carefully. Failure to do so often leads to avoidable mistakes. If you have a chronic illness, it also pays to know when you should refill any prescription. This way, you will not run out of the drugs you depend on. If your vision isn’t what it used to be, ask your pharmacist to make labels with large print if you have trouble reading.
7. You should contact your health care provider immediately if you experience any problems or side effects with your medication. This is especially the case when you receive a drug that you haven’t taken before. You can assume that there will be no adverse interactions with other drugs you take, but you can never be certain on this point until you start taking the new medication. Some patients often believe that a side-effect is something they should expect, but this may be untrue. The only way you can be certain a side-effect is common or uncommon is to seek the advice of your health care provider.
8. Take your medication list with you when you see your health care provider. If you have more than one doctor--chances are that you will if you have a chronic illness--make sure that each one knows what the other is prescribing. Keep your medication list current in terms of both the drugs you take and their dosages.
9. Periodically, you should ask your primary caregiver or pharmacist to run your medication list through a drug interactions database to identify possible problems. This is particularly something you should do if you take five or more drugs. This is highly likely if you have more than one chronic condition.
Don’ts
1. It is generally recommended that you should not take any medication that has expired. At least once a year, a local TV station will warn you of the dire consequences of not discarding all expired medications. However, many drugs don’t expire exactly when it says on the label. Check with your health care provider to see if you can use a few remaining pills in a prescription before tossing the bottle.
2. You should not keep different medications in the same container but separate from other medications. There are apparently some drugs that can interact with each other in a harmful way even before you take them.
3. Don’t stop taking a medication or change the way (time/dosage) you take it without talking to your health care provider. He or she may have some suggestions on how you can obtain the most benefit with the best schedule for you.
4. An emerging problem in the U.S. is the misuse of prescription drugs. You have been warned to never share your medication with someone or to take medication given to you by someone other than your health care provider. We know this sometimes happens, but it can be a bad practice if it occurs on a regular basis.
5. You should never stop taking a medication without first talking to your health care provider. If you are having problems with a certain medication, there may be another choice. Your provider can determine that. Some medications must be stopped gradually to avoid problems. Perhaps the best example of this issue is people who take corticosteroids to manage their condition. These should never be abruptly halted as it could result in other problems.
Health care professionals and polypharmacy
Health care professionals interpret the word polypharmacy differently. It refers not only to the taking of multiple drugs, but also to the problems that may result from this action. The definition of the term is that it describes the use of multiple drugs that are taken by the same patient, most commonly by older patients. It includes also the administration of excessive medication.
As most drugs are dispensed as single-agent formulations in the U.S., polypharmacy though using many drugs administered to the same patient, needs to be differentiated from drug combinations, single preparations containing two or more drugs as a fixed dose, and from drug therapy combinations where two or more drugs are taken separately for a combined effect. When considering polypharmacy in light of the above definition, health care professionals need to consider several questions in prescribing drugs.
These are:
1. Is each medication required by the patient? Pharmacology is an ever-changing field. The use of multiple drugs for a chronic condition that were valid yesterday may not be today. Health care providers and pharmacists need to keep up on current prescribing practices. Clinicians using only medications that have demonstrated usefulness for a given condition can minimize polypharmacy. This might seem a simple solution, but it becomes much more complex when a patient experiences two or more chronic conditions at the same time. Continuing education for providers and pharmacists, plus the use of computers to pick out potentially harmful interactions, provides the best solution to the issue.
2. Are there reasons that a drug shouldn’t be taken by older patients? Inappropriate prescription drug use in the elderly is considered as a major cause of morbidity and mortality in the United States. The challenge faced by health care providers and pharmacists is to determine which drugs are safe or unsafe for elderly patients. This illustrates again the importance of continuing education for both health care providers and pharmacists.
3. Are medications that duplicate another drug being prescribed? Duplicate medications may contain the same active ingredient, or the patient may be taking more than one drug from the same general pharmacological class. Another form of duplication is in therapeutic or adverse effects.
4. Is the patient taking the lowest effective dosage of a prescribed drug? The basic rule is to start low with a medication and see what happens. The dosage of the drug can then be stepped up as necessary in order to control the patient’s health condition. The lowest dose should be based upon a patient's age, health status, liver and kidney function, comorbid conditions, and concurrent drug regimen. Since the pharmacokinetics and pharmacodynamics of many drugs are altered by normal physiological changes of aging, the clinician needs to consider what effects aging may have on a particular drug in a specific patient. The complementary part of the equation is that the clinician must consider when the dosage of a drug can be reduced in a patient. This is often referred to as stepping down the dosage. While stepping up dosage pose few problems to a patient, the question of stepping down the dosage of a drug is often ignored unless addressed by both patients and their health care providers. If you think you need to take less of a drug, talk to your doctor.
5. Is the medication prescribed in order to treat the side effect of another drug? The more medications that are added to a treatment regimen, the greater the chance for adverse effects. If medications do not relieve the symptoms or if they aggravate them, or if the patient experiences new symptoms, health care providers need to determine which of these problems are the result of disease and which are related to medication. It is up to you, however, to inform your health care provider of your concerns.
6. Are there potential drug interactions? When prescribing multiple medications, health care personnel and pharmacists must regularly evaluate a regimen for potentially significant drug interactions. Medications may interact with other prescription or over-the-counter products, foods, diseases, and with natural or herbal products. Genetic predisposition and concomitant use of alcohol or tobacco products may also initiate a drug interaction. These interactions may often be found when a drug is introduced to the public. Although all testing has been done to satisfy the requirements of the Federal Drug Administration, interactions of that drug with others taken by the patient may be unknown. We recall a situation when a promising drug was initially used to treat asthma. Things went well until patients also received antibodies. The interactions between the two types of medications enhanced clearance of the asthma medication from the body, thus diminishing its effectiveness.
7. Is the patient adherent or compliant? A series of common barriers to adherence have been presented on this site. There is any number of reasons a patient may be noncompliant. For this reason, it is a problem that can only be resolved through successful cooperation between patients and their health care providers.
Comments
This brief essay presented a synopsis of polypharmacy by describing the two general definitions of the term. As was pointed out, what the patient may call polypharmacy is much different than how the term is used by clinicians and pharmacists. There are certainly compelling reasons for the two uses of the term, but it is nevertheless unfortunate that polypharmacy has such disparate meanings.
Our reasoning here is that, like the terms medication compliance or adherence, they are often used mainly to describe patient behavior. Polypharmacy is going to prove to be a difficult matter to address with an increasing number of comorbid conditions. For this reason, it is hoped that the term does not become yet another word that can be used in a blame game between health care providers and their patients, but as a problem that can only be addressed through total cooperation of both parties.