April 28, 2015

Polypharmacy and Diabetes – Part 2

In the previous blog I used the following - 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.

I had wanted to say then that often the elderly are prescribed a statin because of slightly elevated cholesterol. Yet the doctors seldom do a benefits analysis to determine if it might be better to withhold statins. These doctors would rather prescribe statins which dramatically increase the risk of type 2 diabetes. I know this because I have a friend that was prescribed a statin at the age of 88 that did not have diabetes. Last month (at age 89) he was diagnosed with type 2 diabetes and Allen and I have been working with him to help him manage his diabetes. And I have personal experience because the doctor rushed to prescribe a statin for my wife about 22 months ago and now she has type 2 diabetes.

Another problem all of us face today is the direct-to-consumer advertising. It is blasted at us daily and a few of the side-effects which may be mild are rushed through and not actually spelled out. The medications are hyped as the latest and greatest. Then many patients and their families demand the medication. Even more problematic is that they then ignore warnings about why the drug may not be in the best interest if the patient.

The lay media frequently report outcomes of clinical trials, often before complete reports are available to physicians through the medical literature. Brief reports in the press may give false hopes or heightened expectations for the benefits of new therapies without adequate explanation of their inherent risks. This drives demand from patients or their families for additional treatment.

Multiple medications creates problems unknown in medicine and is often underestimated by the medical profession. By increasing the number of medications, doctors increase the risk of adverse reactions – remember in the elderly there is no research to say they are safe. The aging process, other chronic illnesses or diseases, and polypharmacy places the elderly at increased risk of adverse reactions.

Now with this in mind, polypharmacy has additional problems, including but not limited to:
  • Risk of duplication of therapy (multiple agents in the same class and generic and brand name versions of the same medications)
  • Risk of patients seeing multiple prescribers and no one conducting oversight of the drug regimen (read my blog on this here)
Medication adherence among patients with chronic conditions is disappointingly low according to doctors. Doctors seem inclined to overestimate the degree of medication adherence. Adherence rates are diminished by:
  1. Complex drug regimens
  2. Incomplete explanation of drug benefits and side effects
  3. Lack of recognition of a patient's lifestyle
  4. Cost of medications
  5. Communication style with the patient
  6. Avoidance of including the patient in the decision
Adherence to a course of therapy is more positive when a patient understands the reasons for taking a medication and is involved in the decision to prescribe. Patients are more likely to have confidence in the prescriber if they are given basic knowledge of potential adverse effects and advice about what to do if such effects occur. Increasingly, clinical practice guidelines are incorporating quality of life and patient preferences to increase adherence by both physicians and patients. Finally, when doctors suggest generics instead of the more expensive brand name drugs. Read my blog on what doctors are saying about patients being noncompliant.

Review of a patient's drug therapy should begin with assessing the patient's adherence, asking about problems with side effects, and determining whether the provider's drug list in the patient's record matches the patient's own drug list. Asking patients to bring all of their medication containers to routinely scheduled office visits can facilitate this effort. Doctors can also help patients recall the need for each of their medications by adding the purpose to the directions for use in their written prescriptions (i.e., “once daily for blood pressure” or “two times a day and take with meal for diabetes”).

The medication list should include all prescription medications, including those taken routinely and those used on an as-needed basis; over-the-counter medications; herbal products; and vitamins or nutritional supplements. Medication lists constructed from memory or even from written lists are notoriously misleading and incomplete compared to examination of the actual medication containers.

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