April 18, 2017
Are You Taking Too Many Pills?
Normally, I would not take a topic from the NY Times. However, since this is one of the better articles on polypharmacy, and covers the topic quite well, I will use it.
About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.
The above statement is very powerful, but most hospital administrators care less as long as they make their bonus. Many hospitalists send patients home on the same or more pills than they prescribed for them while in the hospital.
The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.
Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But, older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.
Some drugs are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.
Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.
For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)
Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.
Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.
Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it could reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.
So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.
The above paragraph shows the problems that doctors have and the possible influence of Big Pharma on their prescribing habits. Unfortunately the following paragraph is also true and adds to the problems.
Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.
To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.
Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”
Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.