April 27, 2015

Polypharmacy and Diabetes – Part 1

Again, I am listing a few of my prior blogs on polypharmacy rather than rewrite them. I find this a very interesting topic and one that I am fighting at the same time, as I take more medications than I like.

Polypharmacy is the shame of our doctors, the FDA, and Big Pharma. Polypharmacy is a problem all people, but especially for those of us with diabetes. Problems inherent in polypharmacy include:
  • Half of the people with type 2 diabetes are over the age of 65
  • No research is done to determine how diabetes medications affect the elderly
  • Doctors stack oral medications on the elderly with no research verifying that they will benefit them
  • Doctors then complain about the elderly and others of not taking their medications
  • No research has been done to determine how other medications prescribed will affect diabetes medications
  • Many of the elderly are over medicated excessively.
There is basically no research done on the elderly (for any medication) to determine if the medications prescribed will perform as intended or if the elderly will get the benefit.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, pharmacy, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

Polypharmacy is a risk factor in the treatment of type 2 diabetes. In normal use, polypharmacy means the concurrent use of multiple medications in the same patient. What is forgotten in most definitions is the potential for harm that polypharmacy may pose for the individual. Other definitions have appeared in the medical literature that put the problem of polypharmacy in a broader perspective. One defines polypharmacy as the “prescription, administration, or use of more medications than are clinically indicated, or when a medical regimen includes at least one unnecessary medication.

Having written the above, I will admit that polypharmacy may be unavoidable. This is because multiple drug therapy has become a standard of care in most chronic conditions. The comorbidities of diabetes commonly include hypertension (blood pressure), dyslipidemia (cholesterol), depression, and coagulopathies (any disorder of blood coagulation), each of which may require one or more drugs for adequate control. Then add to this other conditions that often accompany diabetes, such as hypothyroidism, heart failure, and osteoporosis, and the total number of possible medications needed becomes significant. Lastly, the fear that doctors have about hypoglycemia, and they add oral diabetes medications on top of oral diabetes medication, up to four different medications.

As people age, the chance for other chronic conditions increases. With the availability of multiple medications and the variety of “expert” guidelines for the treatment of these conditions, additional drug therapy is often indicated. Debate has emerged about how many conditions need to be treated.

The burden of polypharmacy falls especially hard on the elderly, who incur the highest incidence of chronic conditions coupled with reduced or fixed incomes and therefore inability to afford the cost of multiple medications. Treatment of elderly patients with diabetes requires special considerations, especially in how aggressively diabetes should be treated. Treatment decisions should consider age and life expectancy, comorbid conditions, cognitive status, living arrangements, and severity of vascular conditions.

The variety of “expert” panel recommendations, clinical practice guidelines, and other national standards for medical treatment has grown exponentially in the last decade. The National Guideline Clearinghouse listed greater than 1,650 active clinical practice guidelines in July 2005, 386 of which were devoted to diabetes alone. Many of these guidelines overlap, and sometimes they contradict each another.

Clinical practice guidelines rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time. Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines.

The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “experts” could care less about treating the elderly.

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