Medical Matters: Prescribing a cut in the number of drugs could improve quality of life

Polypharmacy becomes a problem: is ‘deprescribing’ the answer?


Should your doctor suggest on your next visit that he would like to carry out a so-called “brown paper bag test” on you, it doesn’t mean you are about to be asked to deposit some bodily fluid in an environmentally friendly receptacle.

Don’t be alarmed. It’s simply the process of asking you to bring all your medications along with you as a way of checking exactly what drugs you are taking and to cross-check them with the list of medications on your chart.

A renewed focus on polypharmacy – the concurrent use of multiple medications by an individual – is the likely reason for such a request.

The subject of a recent major report from the King’s Fund in the UK and a growing topic in medical journals worldwide, the phenomenon is driven by our ageing population and the rising number of people living with multiple chronic conditions.

When combined with newer medications aimed at prevention and practice guidelines that recommend multi-drug regimens, the prevalence of polypharmacy is firmly on the up.

Multiple prescription drugs
It is estimated that about one-third of older people in the US and Germany and almost two-thirds in Canada use five or more prescription drugs.

According to the King’s Fund report, Polypharmacy and Medicines Optimisation: Making It Safe and Sound, a Scottish study of more than 300,000 patients of all ages found that between 1995 and 2010 the proportion of patients receiving five or more drugs increased from 12 per cent to 22 per cent and the proportion receiving 10 or more drugs rose to almost 6 per cent.

The authors suggest that “appropriate polypharmacy”, when use of medicines has been optimised and they are prescribed according to best evidence, can extend life expectancy and improve a patient’s quality of life.

But “problematic polypharmacy” can increase the risk of interactions and adverse drug reactions as well as negatively affecting a person’s quality of life.

And the risks of problematic prescribing are considerable.

According to the online medical journal Medscape, some 13 per cent of older people taking five or more prescription medications experienced adverse reactions that required medical attention.

In primary care, it is estimated that about one in five prescriptions issued for older adults is inappropriate.

Speaking to the journal, Australian medicines expert Dr Ian Scott says polypharmacy is a “big problem everywhere”.

“As physicians, we do not appreciate the burden that we impose on people with multiple drugs. It is not just the side effects or the drug/drug interactions, but for older people, it is simply the cognitive burden of trying to remember to take medications on a regular basis and ensuring that they don’t miss any medications.”

Side effects
And he says that many may attribute symptoms to simply getting older and their body becoming weaker, when they may in fact be due to the side effects of the drugs they are taking.

Scott and his colleagues have put together a series of steps for “deprescribing” in older adults taking multiple drugs.

In what may prove a controversial approach, they propose that doctors estimate the life expectancy of patients at high risk of adverse drug reactions and define overall care goals in the light of this life expectancy.

Then, having estimated the risk benefit ratio of each drug, identify those that could be discontinued for that particular person.

Scott acknowledges that it is not easy: “In the work that we have done with prescribing physicians, we have found that they do have the concern that we cannot predict with certainty in any individual patient whether stopping a drug may necessarily be a good or a bad thing.”

Clearly patients will also have concerns, although some may be relieved to have fewer medications to take.

That famous quote from William Osler – “one of the first duties of the physician is to educate the masses not to take medicine” – comes to mind.

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