Polypharmacy: Evaluating Risks and Deprescribing

 

Am Fam Physician. 2019 Jul 1;100(1):32-38.

Author disclosure: No relevant financial affiliations.

Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes. There are several risk factors that can lead to polypharmacy. Patient-related factors include having multiple medical conditions managed by multiple subspecialist physicians, having chronic mental health conditions, and residing in a long-term care facility. Systems-level factors include poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics. Tools that help identify potentially inappropriate medication use include the Beers, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to right treatment) criteria, and the Medication Appropriateness Index. No one tool or strategy has been shown to be superior in improving patient-related outcomes and decreasing polypharmacy risks. Monitoring patients' active medication lists and deprescribing any unnecessary medications are recommended to reduce pill burden, the risks of adverse drug events, and financial hardship. Physicians should view deprescribing as a therapeutic intervention similar to initiating clinically appropriate therapy. When deprescribing, physicians should consider patient/caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to slow disease progression, prevent health decline, and address symptoms. Point-of-care tools can aid physicians in deprescribing and help patients understand the need to decrease medication burden to reduce the risks of polypharmacy.

As the size of the older adult population (those older than 62) and the number of younger people with complex health conditions have increased in the United States, polypharmacy has become a growing problem.1  Polypharmacy has negative consequences for patients and the health care system (Table 1).217 For example, patients taking more than four medications have an increased risk of injurious falls, and the risk of falls increases significantly with each additional medication, regardless of medication type.18

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should identify and prioritize medications to discontinue and discuss potential deprescribing with the patient.3134

C

Expert consensus and narrative review articles

When deprescribing, always develop a specific follow-up plan with the patient.31,33,38,41

C

Expert opinion from review articles

Once a medication reconciliation and deprescribing plan has been put into place, it should be considered at each visit as time allows and comprehensively reviewed at health maintenance visits.19,20,29,32

B

Cochrane review with inconsistent and limited evidence and expert consensus

Before starting any new medications, consider underlying causes to treat first, necessity of treatment, alternative nonpharmacologic treatments, and benefits vs. risks of treatment.13,26,29,32,40

C

Survey study, narrative review, and expert consensus

When starting any new medication, consider it a trial rather than a permanent addition.13,26,32,40

C

Survey study and narrative review articles

When refilling medications, consider the benefits vs. risks of continuation in the short term and long term.13,26,32,40

C

Survey study and narrative review articles


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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ANNE D. HALLI-TIERNEY, MD, is an assistant professor and geriatrician at the University of Alabama Family Medicine Residency and a physician at the DCH Regional Medical Center, both in Tuscaloosa....

CATHERINE SCARBROUGH, MD, MSc, FAAFP, is a faculty member at St. Vincent's East Family Medicine Residency Program at Christ Health Center in Birmingham, Ala.

DANA CARROLL, PharmD, is a faculty member at Auburn (Ala.) University Harrison School of Pharmacy and is an adjunct faculty member in the Department of Family, Internal and Rule Medicine at the University of Alabama.

Address correspondence to Anne D. Halli-Tierney, MD, 850 Peter Bryce Blvd., Tuscaloosa, AL 35401 (e-mail: halli002@ua.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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