A guest column by the American College of Physicians, exclusive to KevinMD.com.
I recently saw a 74-year-old patient to establish ongoing care. In reviewing her medical history, she presented me with the list of the 15 medications she was taking. I was a bit shocked given her medical history which really consisted of only the “usual” issues commonly seen in her age range, including hypertension, hyperlipidemia, and osteoarthritis. But she had no complex medical conditions for which a larger number of medications would be expected. She also did not seem like someone who would actively seek out overly aggressive medical care, particularly since one of her first questions to me was whether she really needed to take all of these drugs. She explained that she has trouble keeping her medication dosing schedules straight (“it seems as though all I do is take medicine”), she dislikes the way some of them make her feel, and the money she is spending on copays has a real impact on her fixed income. And to top it off, at least two of her medications were straight off the Beers list.
Most of us are keenly aware that many patients are taking either too many drugs or are taking medications that either may not be of benefit or might actually be harmful to them. Surveys show that over half of individuals older than 65 years in the U.S. take four or more prescription drugs, and that upwards of 30% of these patients may be taking at least one that is potentially inappropriate.
I’m an internist, and medications are a key tool I have available to treat patients — using medications effectively and safely is what I’ve been trained to do. But I can’t help wonder why so many patients end up on so many drugs, particularly when we know that polypharmacy and inappropriate prescribing in older people are associated with increased adverse drug events, risk of falls, hospital admissions, and death. So why do we prescribe so many medications in the first place, and why are we so bad at stopping or at least reducing unnecessary or inappropriate medications?
A fair amount has been written about this complex issue, but there are several factors related to how we use medications with our patients that I struggle with on an almost daily basis.
I find that attempting to treat patients according to single-disease-specific guidelines can be a significant driver of polypharmacy. Evidence-based guidelines are immensely valuable in helping us know what works and what doesn’t for specific conditions. However, strict application of individual guideline recommendations in patients with multiple medical problems can rapidly increase the number of medications an individual may be taking. Because guidelines typically focus on a single condition, they don’t typically consider the long-term net benefits and harms associated with all of the medications older patients with multiple chronic conditions may be taking. This creates potential conflict between applying best evidence to patient care and minimizing the overall burden of drug treatment and potential interactions between medications. This process of carefully tailoring medical treatment to an individual patient’s is perhaps one of the more “artistic” aspects of medical practice, but one that is a never-ending challenge.
The fragmentation of care so predominant in our current health care landscape is also problematic. Despite carefully crafting a particular medication regimen for most of my patients, visits to the emergency department, admission to a hospital with a restricted formulary, and appointments with other specialists and subspecialists frequently result in substantial increases in the number of medications prescribed to my patient, or changes in dosing or “therapeutic interchanges” where my patient is now on a different drug within the same class than they were initially. And it is often difficult to determine why some of these changes were made, as well as the indication for which some drugs were started. On more than one occasion I’ve seen medication started to treat the side effects of another medication. I believe that this is what happened to my patient — by being followed by multiple physicians in different specialty and subspecialty areas, she simply gradually accumulated treatments based on each clinician’s attempt to address a specific condition or symptom.
There also seems to be an element of deference to others in terms of medication management. For example, if a specialist or subspecialist with expertise in a particular disease area started a medication, it must be important, and it would be wrong to question its indication or consider stopping it.
And “therapeutic inertia” also seems to play a significant role. Given all of the other stresses and time pressures associated with caring for patients these days, it is often easier and more efficient to simply continue drug therapy the way it is without reviewing or questioning the need for treatment. If you throw in concerns that patients may negatively interpret discontinuation of medications as withdrawal of care or evidence of suboptimal or disjointed medical care, it is usually just easier to let things be.
So what to do? Unfortunately, there doesn’t seem to be an easy solution to this problem. However, good medical practice dictates that all of us – specialists, subspecialists, emergency physicians, and hospital-based clinicians, in addition to primary care physicians — perform due diligence in our use of medications by intentionally and thoughtfully considering our prescribing practices with each patient. Each of us need to ask several important questions whenever we prescribe medication: Is there truly an indication for drug treatment? If so, how will it fit into the overall context of the treatment of the patient to avoid or minimize potential drug interactions and negative side effects? How long will the treatment be needed? If I am adding to or changing a patient’s medication regimen, will the change be truly beneficial and worth the potential increase in cost to the patient (particularly if changing from an older drug to something new)? And if I am making a therapeutic interchange, is it intended to be temporary or permanent, and if permanent, why?
And perhaps the most important aspect of this responsibility is communication — communication with other clinicians (particularly those who will be following the patient longitudinally) about the rationale, plan, and details for drug treatment, and patients themselves who have the right to know what they are expected to take and why, and be given an opportunity to be involved in therapeutic decision making. If we all did these things, I suspect that polypharmacy and inappropriate medication treatment would decrease significantly.
Unfortunately, there is also often little guidance to physicians in tapering, stopping, discontinuing, or withdrawing drugs. There are few studies of deprescribing, and those that exist have focused on the tolerability of deprescribing as opposed to actual clinical outcomes. The good news is that most suggest that medications can be successfully withdrawn with little to no harm to the patient. However, this lack of helpful data requires clinicians attempt to taper or stop medications based on clinical experience and judgment rather than using an approach guided by evidence. Clearly, more research is needed.
My patient and I are actively working to trim her regimen, and I think we may be able to reasonably get her down to around three daily medications, and she is thrilled. But doing this is a long-term process that takes time. And it is perhaps one of the strongest arguments that to avoid the need for deprescribing; it is best not to start so many medications to begin with.
Deprescribing is undoing what we’ve collectively done, ideally for the benefit of our patients. But perhaps this isn’t a bad thing.
Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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