ATLANTA—In a session at the 2019 ACR/ARP Annual Meeting, Susan Chrostowski, DNP, assistant clinical professor at Texas Woman’s University College of Nursing, Dallas, told the audience that she’d had a visit with a patient and asked how he was doing.
“Not too good,” he said, explaining that his chest hurt.
“What’s the matter with your chest?” she asked. The man replied it had to do with the airbag going off.
“Why did the airbag go off?” asked Dr. Chrostowski, increasingly perplexed.
The man said he “didn’t know what happened,” but all of a sudden a car just came right toward him. Dr. Chrostowski noticed on the man’s long list of medications that he had recently stopped taking the anti-seizure drug phenytoin and asked why he’d done that. He replied that another doctor said he might be able to get off the medication, but to check with his neurologist about it. Instead, the man, not wanting to be bothered with a neurology visit, simply stopped taking the medication, and the car wreck was likely related to a seizure he had while driving.
Challenges of Polypharmacy
The exchange underscores the challenges medical professionals face in helping patients navigate confusing and burdensome polypharmacy. Often, they can’t keep track of when they’re supposed to take their medications or how much to take—or even know why they’re taking them in the first place. Efforts to keep things straight are complicated by other factors, such as in the case above, when one doctor suggests a patient stop taking a medication but the patient doesn’t follow the proper procedure to do so.
“These are some of the problems we encounter,” said Dr. Chrostowski.
Kam Nola, PharmD, MS, professor and vice chair of pharmacy practice at Lipscomb University College of Pharmacy, Nashville, Tenn., said a standard definition of polypharmacy does not exist and the definitions used tend not to account for what is appropriate multiple medication use and what is inappropriate.
The term has assumed a negative connotation—she herself thought about polypharmacy negatively in preparing the talk, but that is not the best way to think about it, she emphasized.
“One key point that I want to make when it comes to polypharmacy is that it is not this negative connotation,” Dr. Nola stated. The objective should be to streamline the process so the needs of the patient and care goals are met.
Drs. Nola and Chrostowski mentioned patients they’ve seen who are on 20 or even 30 medications. When they’re asked to bring them all in for a review, they sometimes put them all in shopping bags—purses aren’t big enough.
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.
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.”
Manage the Prescribing & Cancellation Process
Dr. Chrostowski said that de-prescribing is such an important aspect of care for some patients that the very definition of prescribing should be reconsidered.
“We’ve always kind of thought of prescribing as adding more medications,” she said. “Prescribing should be an overall umbrella concept of how we’re managing all of [a patient’s] prescriptions. It could involve eliminating some medications, adjusting doses on others.”
The START (Screening Tool to Alert Doctors to Right Treatment) tool is a way to evaluate a patient’s medication list, with a focus on physiologic symptoms, providing information on the cardiovascular, gastrointestinal and central nervous systems and considerations for pharmacy for each system. It is rooted in evidence-based rules for avoiding commonly encountered examples of inappropriate prescribing and potential screening omissions.
The STRIP (Systematic Tool to Reduce Inappropriate Prescribing) tool is another systematic way to manage the prescribing and de-prescribing process, incorporating patient preferences.
“You actually look at [the patient’s] drug history, analyze the drugs they’re taking and come up with a treatment plan,” Dr. Chrostowski said. “You really have to have the patient on board to make any kind of medication changes.”
The de-prescribing process can run into hurdles: Some therapies are recommended by guidelines. There can be concern about withdrawal side effects. Some prescriptions may have been initiated by another provider. There may not be enough time to go through the process. Patients themselves may resist getting off medications, despite the added simplicity and lower cost related to taking fewer drugs.
“We like to think patients are going to be willing to get off medications and reduce their drug costs—and a lot of times that is the case, but not always,” Dr. Chrostowski said. “It may take several efforts. You may have to really have some discussions about the reasons behind this [and] the concerns about their long-term health.”
Thomas R. Collins is a freelance writer living in South Florida.
- Bechman K, Clarke BD, Rutherford AI, et al. Polypharmacy is associated with treatment response and serious adverse events: Results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatology (Oxford). 2019 Oct 1;58(10):1767–1776.
- Kaiser Family Foundation. Retail prescription drugs filled at pharmacies per capita: 2018. https://www.kff.org/health-costs/state-indicator/retail-rx-drugs-per-capita/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
- Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: Results of an international, cross-sectional study (COMORA). Ann Rheum Disease. 2014 Jan;73(1):62–68.