The Polypharmacy Problem Polypharmacy is described as taking five or more medications daily. One survery found that more than 50% of female Medicare beneficiaries took five or more medications daily, with 12% taking 10 or more medications daily. There is a great opportunity to reduce the number of medications taken by patients, with the potential to reduce both side effects and drug interactions. 1. Stool Softner: There is no evidence docusate (Colace) is effective for what it is used for- softening the stool and prevention of constipation. In a randomized trial, 170 people with chronic constipation received either 5.1 g psyllium or 100 mg docusate twice daily. Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective matter of constipation. 2. Antibiotics before Dental Procedures: Following changes to the antibiotics prophylaxis guidelines for the prevention of Endocarditis in 1997, clinicians should be prescribing far fewer antibiotics before dental cleaning or procedures. Many patients are still receiving antibiotics before procedures because they are having prosthetic joints, even though there is no evidence to support this practice and the most recent American Academy or Orthopedic Surgeons (AAOS) and American Dental Association (ADA) recommendations do not encourage it. In 2015, ADA guidelines strictly recommends against it. This advise may not apply to transplant patients, and the decision to premedicate for invasive dental procedure and the selection of appropriate regimen should be taken on case-to-case basis. 3. Proton Pump Inhibitor: PPIs are associated with reduced absorption of Calcium (with increased fracture risks), B12, and thyroid hormone absorption, along with acute ad chronic injury and clostridium defficile infection. Mortality may also be increased with PPI users. Some patients may need PPIs long term (eg; refractory reflux disease, and elderly patiets on chronic nonsteroidal anti-inflammatory drug therapy). However any other patients are prescribed PPIs. They are often prescribed for stress ulcer prophylaxis in hospitalised patients but arent needed after discharge. Another common use of PPis is for abdominal without a recognized source; in this situation, it makes sense to try taking the patient off of the PPI. The data on the benefits versus harms of deprescribing PPIs are inconclusive. A Cochrane review found that deprescribing PPIs can increase gastrointestinal symptoms while reducing pill burden. 4. Stains for Primary prevention: With the release of American heart Association guidelines for Statin use in 2013, there has been significant increase in the use of statins for primary prevention, bu there is a paucity of evidence on the benefits of statins for primary prevention in patients over the age of 75 years. Statins can be associated with muscle symptoms and an interract with several drugs, increasing toxicity in elderly. There is a difference between potential benefits of statins for secondary (after cardiovascular event stroke) versus primary prevention. The risk versus benefits of primary prevention is a particular concern in patients over the age of 80. 5. Benzodiazepines/ Z Drugs: Benzodiazepine use is strongly correlated with increased fall risk. Zolpidem has also been linked with increased fall risk. Insomnia, a common concern in older atient is often managed pharmacologically, but the chronic use of benzodiazepines and the "Z drugs"- zolpidem, zaleplon and eszopiclone- should be avoided. In elderly patients, the risk of stacking of sie effects and risk is very real. Many elderly patients are on selective serotonin reuptake inhibitors (SSRIs) and may also be taking a benzodiazepine to treat the insomnia caused by SSRIs. All 3 of these drug groups- benzodiazepines, SSRIs and Z drugs- raise the risk for fall in the elderly. 6. Beta-Blockers: In 2011 American Heart Association/ American College of Cardiology Foundation guidelines, beta blockers use was recommended for 3 years after either a MI or acute coronary syndrome (ACS) in all patients with preserved left ventricular function (class I recommendation, grade B evidence). As a class IIa recommendation, the guideline stated that it was reasonable to continue the beta-blocker therapy beyond 3 years in patients with the history of MI or ACS. More recent data have not shown long term mortality benefit with prolonged beta-blocker after MI or ACS in an era when reperfusion therapies are common. Furthermore, beta blockers are not very potent antihypertensive agents and are less effective than other options for the treatment of hypertension in the elderly. Atenolol in particularly ineffective for prevention of negative outcome from hypertension. 7. Drugs for Asthma/ COPD: Many patients with shortness of breath are diagnosed with asthma or chronic obstructive pulmonary disease (COPD), and when their symptoms do not resolve, more drugs and higher doses are prescribed. In recent study, one third of the patient with a current diagnosis of asthma had normal respiratory tests (spirometry/peak flow) and had no problems with weaning off of asthma medications. The same high rate of incorrect asthma diagnosis has been shown in several other studies over the past few years.The major culprit in misdiagnosis was not using spirometry to make the diagnosis. This is a good area in which to practice deprescribing. Some patients with asthma or COPD are misdiagnosed, other may not have active asthma and medication could be weaned. 8. Antimuscarinics for Urinary Incontinence: The antimuscarinic agents (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine and trospium) used commonly for the treatment of stress urinary incontinence have a small benefit. These drugs have strong anticholinergic properties and can cause major side effects, especially in elderly populations. For example, oxybutynin resolved urinary incontinence in 114 of 1000 treated patients, while 63 of 1000 stopped treatment because of side effects. 9. Cholinesterase inhibitor for Dementia: This is another drug class with very modest benefit and many disconcerting side effects. the number needed to treat for any benefit in patients with dementia for Donepezil (the most commonly prescribed cholinestrase inhibitor) is 12. This means that for every patient who obtains a modest benefit from this drug, 11 will be treated but have no benefit. The side effects are disturbing with this class of drugs and include nausea, decreased appetite, weight loss, syncope, and urinary incontinence. Some patients may even be started on antimuscarinic agents for the urinary incontinence cause by the cholinesterase inhibitor they are taking. 10. Muscle Relaxant for back pain: The evidence of benefit is insufficient for the sue of mucle relaxants for the treatment of subacute or chronic back pain. This class of medications produces a great deal of side effects and is especially dangerous in elderly. Toxicity is increased when combined with alcohol. 11. Supplements: Many patients take over-the-counter supplements. Taking a multivitamin is particularly common, although no benefit in cardiovascular disease or cancer prevention has been shown. Calcium suppliments are also unlikely to benefit postmenopausal women. In the largest study to date, calcium and vitamin D supplementation slightly increased bone density and frequency of kidney stones but did not reduce fracture risk. Calcium supplementation does not inhibit thyroid hormone absorption. Source
