There are many roads we can travel with our medications. We can keep adding medications as the number of health problems we develop increases. We can stop taking medications as the side effects of these medications compound, or when our symptoms ameliorate. Once we start on a medication pathway, there are consequences. Despite that, very few of us have a major say in our medications.
Patients need a deprescribing consultation
Single drug prescribing can be dangerous due to allergic responses, lack of efficacy, side effects, and excess costs, to name a few reasons. Polypharmacy is even more dangerous as adverse outcomes can compound. Polypharmacy is the prescription of five or more drugs. Recently, a new term — hyper/excessive polypharmacy — has been coined. It refers to people typically using ≥ 10 medications at any one time. The number of people experiencing polypharmacy has quadrupled over a 20-year period, while an Australian based study highlighted a 52 percent increase in polypharmacy between 2006–2017.
The exponential rise in the number of medications any one patient is taking is not surprising. With repeat prescriptions being generated automatically without the need for any medical consultations, medication review and medication optimisation rarely occurs within clinical practice for the older population.
Lower socioeconomic status has been associated with higher polypharmacy. Individuals of lower educational backgrounds displayed 21 percent higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar results have been noted based on occupation and income.
So less is more. It is time to take deprescribing, or the reduction of medications, seriously. One of the most comprehensive definitions of deprescribing could be “the supervised process of intentionally stopping a medication, reducing its dose, or replacing it with a safe alternative in order to improve patients’ outcomes and reduce adverse drug events.” Deprescribing can take one of four forms: complete withdrawal of a medication, tapering of doses, reducing doses, or switching to an alternative medication with a better benefit-to-harm ratio.
Patients need to ask for a deprescribing consultation. Not only to reduce polypharmacy, but also to prevent a dangerous prescribing cascade. A prescribing cascade is a clinical situation whereby a set of signs and symptoms is incorrectly interpreted as a disease and is consequently treated with the introduction of a new medication, instead of performing a medication review and identifying the new signs and symptoms as negative side effects of a medication previously prescribed. This phenomenon was first described nearly 20 years ago, but there is no evidence that it is subsiding.
The most common medications causing prescribing cascades were blood pressure medicines, mental health drugs and antibiotics.
Before prescribing new medications to patients, clinicians should review the pathways to adding medications to counter side effects of other medications. Patients can also take part in this process by asking their doctors whether adding another medication to their regime is truly in their best interest.
The Thinker 
In the UK general practice, the Quality and Outcomes Framework has been in place for almost 20 years. GPs are rewarded for achieving these standards. Reviewing prescribing for all patients with repeat prescriptions each year is part of the deal. GPs are working flat out seeing patients, so tasks like drug reviews are allocated to pharmacists (often shared between the practices of a GP network). The pharmacists suggest changes so prescribing is less dangerous, in line with guidance, evidence based, using less expensive drugs, etc. They don’t often deprescribe, as the drug removed might just be having some beneficial effect.
When I review patients in care homes nearing the end of their life, I try to trim the list of drugs they take, though this might be seen as discrimination against the elderly, denying them the benefits of preventative medication for example.
Patients prefer taking medication and, at review, want to know if they can stop “X” or cut the dose of “Y”. Doctors and pharmacists will explain the rationale, but patients decide whether they agree or want to take the meds (sometimes because of dodgy internet articles). If they wish to avoid confrontation or annoying the doctor, they may agree but not take drugs.
In general I think most GPs try to reduce polypharmacy, but when time is short, it is easier to kick the can down the road. If I do try to reduce meds, this means more frequent reviews, extra work. And if I stop a drug and a patient then suffers an (perhaps unrelated) adverse event, I might be criticised for my action.
Finally, doctors might prescribe a drug in an acute situation, but this gets added to their repeat prescriptions, as “it seemed to do some good” without scrutinising the need to continue it. Then it becomes entrenched.
Sorry for the long post, but it’s a complicated issue.
LikeLiked by 1 person