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reported to the doctor as well as discrepancies like out of date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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