Living longer increases our likelihood of experiencing more than one chronic health problem at a time. At least one in two older people have more than one chronic disorder with an average number of conditions ranging between 2.5 and 6.5. That is a heavy burden for one person.
Co-morbidity or multimorbidity, as it is now called, can be costly to healthcare systems. Research suggests an almost sevenfold increase in health costs for hospitalised patients with five index health comorbidities.
We also know that multimorbidity contributes to the growing problem of prescription of multiple drugs. Too much prescribing has given polypharmacy a bad name in health circles because it can add additional problems through the compounding of individual side effects and unexpected adverse events from combinations of drugs.
Some authors suggest that disease-specific guidelines are to blame. Rigorous application of guidance targeting disease-specific goals can lead to a series of therapeutic interventions that, on their own, might be alright but together may cause major problems such as serious side effects – for example severe bleeding, which can occur in patients taking heart failure and depression medications at the same time.
The more problems diagnosed, the more drugs prescribed and the closer the patient comes to despair.
The problem for clinicians is that we follow this guidance logic in our thinking about our patients. We prioritise prescribing on the basis of those problems we deem most serious and most urgent. We tend to apply a one-dimensional approach: prescribe for the presenting problem first then sequentially follow-up with the other problems. The more problems diagnosed, the more drugs prescribed and the closer the patient comes to despair – a diagnosis for which our prescriptions are most inappropriate.
A study of more than one million patients over a six month period found that of those patients whose GPs prescribed four or more medications, two of the drugs were for sleeping tablets and pain killers.
Everyone agrees multi-prescribing is a problem but there is no evidence to suggest how it could be tackled (ordered and managed) or how multimorbidity and multipharmacy can work together in individual patients.
Rather than demonising multi-prescribing and reiterating its problematic aspects, wouldn’t it be more productive for the profession to start looking at how rational multipharmaceutics can improve the management of the complex interplay of health problems? This would provide a pathway for multipharmacy to be incorporated into medical education and CME across all disciplines. But this kind of learning will only occur if there is sound evidence to support it.
2 thoughts on “Has the Time Come for Rational Multipharmaceutics?”
A really important topic area, thank you, and NICE are indeed currently working on guidelines around multimorbidity ( https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0704 ). We have already published some work around medicines optimisation ( https://www.nice.org.uk/guidance/ng5 )
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Disease specific guidelines, based on narrowly defined evidence based medicine, are still guidelines. Some GPs already modify treatment in the face of multimorbidity, though in UK this might mean losing out on Quality & Outcome Framework payments. This is usually done on an individual basis, taking into account all the GP knows about the patient. I am a bit uncomfortable with the concept of having a standard treatment for, for example, all my patients with type 2 diabetes, hypertension, osteoarthritis, chronic pain, stress incontinence and constipation (I see at least half a dozen patients with this mix of problems every day). But it’s food for thought. The polypill never caught on, did it?