Drugs: too much or never enough?

Excess prescribing of pharmaceuticals is a nightmare for both patients and prescribers. It’s much easier to add one medication after another than to take a patient off any.  After all, if one is good, aren’t two or three better?  And in countries that lack robust primary care, multiple specialists may prescribe multiple medications without any cross referencing. 

Deprescribing studies should be part of drug approval processes 

We all know about medications that are ineffective or cause harm or potential harm, but what of those that become inefficient? Some pills may be inappropriately expensive or superseded by newer, more effective models. That should be an indication for desprescribing, or even a drug holiday. 

Unfortunately, taking patients off medications or swapping prescriptions is simply not the norm.  Overprescribing is much more frequent than deprescribing, especially in connection with common medical problems such as hypertension and depression. 

Some guidelines for the treatment of hypertension already advise initial use of two antihypertensive drugs. Why? We know that the more drugs a patient is prescribed the less likely it is that they will comply with treatment regimens. Is this the reason that adherence with hypertensive medications is declining?

And then there are the conflicting recommendations that apply to the arbitrary “old age cut off” of 65 years. Older people residing in continuing care communities who are on two or more antihypertensive have an increased risk of death from some of the cardiovascular events they are designed to prevent, for example stroke. 

It is not just at older age where multi prescribing can be lethal. For middle-aged women, who are most at risk of suicide, multiple psychoactive medications, including opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, are commonly prescribed and co-prescribed among women during this period in the lifespan and are a known suicidal cocktail.

As the ingesters of medications, patients possess the ultimate control over deprescribing. We don’t always take our tablets and aren’t always forthright with our health care professionals and family. Many studies show that we are selective about which medications we take and how often. 

Of course, more research is necessary especially in the gap areas such as concordance between prescribers and patients. Viable solutions may take some time as the funding research on prescribing enormously outweighs funding for deprescribing and is currently focussed on the elderly and expensive medications. Even there the results are inconclusive.

Of course, deprescribing is not in the interest of drug companies and they are unlikely to fund such studies.  One way to improve the research funding imbalance is to make deprescribing studies part of initial drug approval processes.  Pharmaceutical companies that develop new products should be required, as part of their regulatory process, to engage in deprescribing pharmacovigilance studies during a drug’s lifetime in the same way as they are required to monitor adverse events.

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