Polypharmacy: So Many Drugs, So Little Time

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Polypharmacy: So Many Drugs, So Little Time

Polypharmacy:So Many Drugs,So Little TimeShannon O. Smith, MDGeneral Internal MedicineConference


Objectives1. Recognize polypharmacy and what it meansto your patients2. Fix it.


Patient Susie Q• 57 year old Caucasian woman• Transferring care from PCP in Chicago• Moving to Madison to be closer to familybecause of her multiple medical problems


Patient Susie Q: Problem List• Mixed connective tissue disease• Breast CA x 2 (with complicated mastectomy& poor wound closure)• HTN• Diabetes• Elevated pulmonary pressures• Malabsorption (of unclear etiology)• Tremor


Patient Susie Q: Problem List• Peripheral neuropathy• Diastolic dysfunction• h/o DVT and PE• Osteoporosis• Chronic nausea• Lower extremity edema• NASH


Patient Susie Q: Meds• Amantadine 100 mg TID• Amiloride 5 mg qhs• Carvedilol 25 mg BID• Cevimeline 30 mg 2 caps BID• Vitamin D 1000 units daily• Clonidine 0.3 mg BID• Domperidone 10 mg 2 tabsqid• Vitamin B12 1000 mcg daily• Doxazosin 4 mg qhs• Enalapril 20 mg once daily• Esomeprazole 40 mg BID• Folate 1 mg once daily• Furosemide 20 mg once daily• Glipizide 10 mg once daily• HCTZ 25 mg once daily• Hydroxychloroquine 200 mgBID• Infliximab 1000 mg IV q6 wks


Patient Susie Q: Meds• Lactobacillus 1 cap once daily • Prednisone 15 mg once daily• Lamotrigine 150 mg BID • Promethazine 25 mg TID• Metformin 850 mg BID • Simvastatin 40 mg qhs• Methotrexate 2.5 mg 8 tabs • Tolterodine 4 mg once dailyweekly• Coumadin 5 mg qhs• Nystatin cream prn • Zinc oxide ointment• Tincture of opium 0.7 mls TID• Reclast 5 mg IV once yearly• Pramoxine HC ointment


Patient Susie Q: Meds• Lactobacillus 1 cap once daily • Prednisone 15 mg once daily• Lamotrigine 150 mg BID • Promethazine 25 mg TID• Metformin 850 mg BID • Simvastatin 40 mg qhs• Methotrexate 2.5 mg 8 tabs • Tolterodine 4 mg once dailyweekly• Coumadin 5 mg qhs• Nystatin cream prn • Zinc oxide ointment• Tincture of opium 0.7 mls TID• Reclast 5 mg IV once yearly• Pramoxine HC ointmentRoughly 60 pills per day!


Polypharmacy: Definition• No standard definition• Some say 2‐9 meds• Some say any time a patient is taking amedicine that is not indicated


Polypharmacy: Prevalence• 57% of women >65 take at least 5 meds• 12% of women >65 take at least 10 meds• Nursing home population: 14‐24% >9 meds


Polypharmacy: Why Do We Care?• Growing population of elderly (72 mil by 2030)• Prevalence increases with advancing age• People are living longer with chronic diseases• There are no natural advocates


How Does It Affect Our Patients?• Compliance• Cost• Drug interactions• Adverse Drug Reactions (ADRs)• Decreased functional status


Compliance• Number of meds is stronger predictor than age• General population compliance:– 80% for once daily dosing– 50% for QID dosing


• Bankrupted Susie QCost


Drug Interactions• Risk increases with # of drugs• Can approach 100% with 8 or more meds


Adverse Drug Reactions (ADRs)• Definition: Harm from a medication given at anormal dose and with normal use• Polypharmacy increases risk of ADRs:– 13% with 2 meds– 58% with 5 meds– 82% with 7 or more meds• Most common drugs: CV drugs, diuretics,anticoagulants, NSAIDs, Abx, hypoglycemics


Decreased functional status• 1989 study of >600 elderly patients:– The more meds, the worse the physical functioningand ability to carry out ADLs• 2011 study showed polypharmacy associatedwith worsening physical & psychological health


How to Fix It• SAIL and TIDE• Borrowed from Werder and Preskorn:Managing Polypharmacy: Walking a Fine Linebetween Help and Harm. jfponline.com


SAIL• Simplify– use meds that are qd or BID• Adverse effects– Be familiar with these• Indication– Make sure each med has an indication and a defined,realistic therapeutic goal• List– List name and dose of each med, and share it with thepatient


TIDE• Time– Allow sufficient time to address & discuss medicationissues• Individualize– Dose adjusting for renal and/or hepatic impairment– Start low and go slow• Drug interaction– Know them!• Educate– Discuss expected medication effects, potentialadverse effects, and monitoring


Take Home Points• Recognize the problem• Be an advocate for your patient• Make sure both you & your patient know theindications for each of their medications• Keep cost & dosing in mind when prescribing• Know potential side effects & drug‐druginteractions• Schedule an appt devoted completely tomedication review & management for yourpolypharmacy patients


Polychildrenism

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