Even though modern medicines help us cope better with chronic disease and other health problems, too many medicines can create other problems for our health.
We use the word “Polypharmacy” to talk about problems people face with too many medicines – and this includes over the counter medicines (or OTC meds), vitamins, minerals, and herbals – not just prescription drugs!
Polypharmacy is the first “red flag” (or warning) that Medicare Australia recognises as a good reason for a doctor to request a Home Medicine Review – that is, when a patient takes 5 or more medicines or 12 or more doses of medicines every day, the medication review is accepted as a first step in the patient’s general health management plan.
When someone takes 20 or more tablets every day it can be confusing so a home visit by a consultant pharmacist will help to sort out any medicine related problems such as;
- Confusion between generic brands of the same medicines
- What time to take medicines
- Taking before or after food
- Bad side effects from your medicines – is there something else with less side effects?
- Too many medicines to remember – a weekly pill or medicine pack may help.
- Do I need to take all these medicines?
De-Prescribing is when we reduce the number of medicines a patient takes because;
- Polypharmacy is causing too many drug related problems and side effects
- Sometimes, using the same drug for too long is just not necessary.
Here are some real-life examples of how this can happen.
Case One: De-prescribing – Fenofibrate and allopurinol therapy are not needed here.
Mrs F has moderate kidney disease, very low fats (triglycerides/cholesterol) in blood and was prescribed low dose fenofibrate to prevent another stroke. Mrs D. also has a history of allergy/skin rash and takes low dose allopurinol every second day to prevent Gout, even though blood levels of uric acid are well within range. [Also, Mrs F has not had an attack of gout for years]
There is no need for Mrs F to take fenofibrate as this is unlikely to help prevent another stroke, is not recommended in severe kidney disease and will probably make allergy/skin problems much worse (especially with allopurinol).
Recommendation: Deprescribe fenofibrate and allopurinol for Mrs F.
Case Two: Polypharmacy
Kidney injury with Meloxicam – a long acting Non-Steroidal Anti-inflammatory drug (NSAID)
Mrs E takes Metformin for diabetes, Ramipril for blood pressure and kidneys, frusemide for too much fluid in legs, and meloxicam (a NSAID drug) every now and then for pain and inflammation from arthritis. In addition, Mrs E was taking meloxicam more often during winter because the pain from arthritis had become much worse.
As a result, she developed acute kidney failure due to triple whammy effect (↓) on blood flow in small capillaries of the kidney.
This was caused by the interaction between Ramipril, Frusemide, Meloxicam.
Recommendation: Deprescribe Meloxicam for Mrs E.
For a more detailed explanation please watch this short animation at the following link – https://www.youtube.com/watch?v=J2YaULhMx5g
[Courtesy of The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health from the U.S. Department of Health and Human Services]
It is easy to see how too many drugs can cause problems for some people though we must be mindful of that fact that as we get older, we may need to take more medicines to avoid other health problems with chronic disease.
Even so, getting your medicines checked once a year will probably help to prevent any problems that may arise from taking too many drugs, vitamins, and herbal medicines, together.
Talk to your doctor or pharmacist about a Home Medicine review – it may just be the best little chat that you could ever have about your medicines.
Emmanuel Pippos, Consultant Pharmacist.