Better Medication Management Needed
The need for better management of patients on multiple medications is clear, Dr. Nola said. Studies have found that polypharmacy is associated with treatment response and with serious adverse events. One study of 22,000 rheumatoid arthritis (RA) patients in the U.K. found that patients were on a median of five medications, not including their RA medications.1 The number of medications increased with age, and surprisingly, smokers were on fewer medications than non-smokers. More medications were associated with higher scores on the Health Assessment Questionnaire Disability Index. And additional co-morbid medications were associated with increased risk of serious adverse events.
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Explore This IssueJanuary 2020
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In the U.S., the per capita number of medications per year is 11.6, according to the Kaiser Family Foundation—the lowest was in Alaska, at 6.4, and the highest in Kentucky, at 18.4.2
Under the Centers for Medicare & Medicaid Services’ Medication Therapy Management (MTM) program, extra monitoring is given to beneficiaries who have multiple chronic diseases and multiple medications, with nine core chronic illnesses as the main focus: Alzheimer’s, chronic heart failure, diabetes, dyslipidemia, end-stage renal disease, hypertension, respiratory disease, arthritis-related bone disease and mental health conditions, including depression and schizophrenia.
Over the past eight years, MTM program monitoring has included an increased number of osteoporosis and rheumatoid arthritis cases. Under MTM, comprehensive medication reviews require documentation of why and how beneficiaries are supposed to use their medications, and patients are given a personal medication list to carry with them at all times—ideally—and a medical action plan covering the dosage, schedule and reasons for medications.
Concerns about polypharmacy include drug-drug interactions, dosing errors, drug-disease interactions, adherence problems and adverse effects in specific scenarios, such as breastfeeding and renal dysfunction.
Among RA patients, a 2014 study found, co-morbidities likely to lead to polypharmacy are depression, ischemic cardiovascular diseases, solid tumors and infectious diseases.3
Providers should always keep in mind the American Geriatric Society’s Beers Criteria—medications that are potentially inappropriate for the elderly, Dr. Nola said. One recent change was that aspirin for primary prevention was added to the “caution” list, and gabapentin and colchicine were added to the “dose reduce” list.
Dr. Nola said providers shouldn’t bristle when pharmacists ask questions about a patient’s list of medications.
“When you get the phone call from a pharmacist related to a particular medication, don’t jump to ‘Oh, they’re questioning what I’m doing,’” she said. “No, they’re verifying and questioning everything, because they’re held accountable to medication-related quality measures.”