Polypharmacy, defined as concurrent use of five or more drugs, can occur in patients of all ages. Polypharmacy may be appropriate or inappropriate. Appropriate polypharmacy is defined as “use of the correct drugs under appropriate conditions [in order] to treat the right diseases.” A prescribed drug becomes inappropriate when its benefits no longer outweigh its risks. Inappropriate polypharmacy has been shown to increase the risks of hospitalization, adverse drug events, clinically relevant drug interactions, and all-cause mortality. Many tools are available to aid physicians in identifying inappropriate polypharmacy. Implicit tools, such as the Medication Appropriateness Index (MAI), provide guidance to be used alongside clinical judgement. Explicit tools, such as the American Geriatrics Society (AGS) Beers Criteria, provide lists of potentially inappropriate drugs and recommend alternatives. Collaboration with pharmacists is important in assessing drug appropriateness. It has been shown to reduce drug-related problems, emergency department visits, and hospitalizations and to improve overall patient health. A patient-centered, team-based approach is recommended in the process of deprescribing inappropriate drugs. Deprescribing should be approached in the same stepwise manner as prescribing of new drugs, and should include patient agreement to changes, evidence-based rationales, and use of dosage tapering strategies.

Case 4. As you review your patient schedule for the day, you notice that you are seeing ST today. ST is a 68-year-old man who takes 23 drugs for diabetes, hypertension, coronary artery disease, dyslipidemia, hypothyroidism, and osteoarthritis (OA). You know that taking this many drugs must be stressful and difficult for ST, but prioritizing drug management has been difficult in addition to managing all of his conditions.

Definitions, Causes, and Effects of Polypharmacy

Polypharmacy commonly is defined as the concurrent use of five or more drugs.^85,86 The presence of even one chronic condition can result in polypharmacy.⁸⁵

Polypharmacy has been shown to be an independent risk factor for hospitalization, adverse drug events, clinically relevant drug interactions, and all-cause mortality.⁸⁶ Polypharmacy also has been associated with specific consequences for the patient and the health care system. Patient-related consequences include frailty, disability, and worsening quality of life.⁸⁵ System-related consequences include increased use of the health care system, decreased physician functionality and productivity, and increased rates of drug errors.