Polypharmacy and deprescribing: what you need to know
As we get older, we tend to find that more things go wrong with our bodies. What’s more, those different problems can exacerbate each other, meaning that older people are far more likely to have multiple problems or chronic conditions.
This means that they may also be taking multiple different medications, a situation known as polypharmacy.
The problem with polypharmacy
In itself, being on several medications should not be a problem. It almost certainly wouldn’t be an issue if all the medications had been prescribed at the same time. That would mean that both prescriber and pharmacist had seen the whole list of medications in one place. However, this doesn’t happen. Instead, the list of medications builds up gently but inexorably over time, as more problems emerge. Pharmacists report that some older people can be on as many as 20 different medications.
The problem with this is that medications all have side effects, some more serious than others. Medications can also interact, causing other symptoms and issues. An alert prescriber or pharmacist may spot a combination of medications that is known to interact unfavorably, and provide an alternative to one or more. However, it is not always possible to spot potential problems, because not all interactions are known.
The net result is that sometimes people may end up on a combination of medicines that actually makes them feel worse than the original condition. Sometimes they may even find themselves taking medications that they no longer need at all. This might be because the original condition has improved in some way. It may also happen that a subsequent medication can replace a previous prescription, but nobody notices that the original drug is still being supplied.
Introducing medicine reviews and deprescribing
Fortunately, there is an answer to this problem: medicine reviews, and particularly deprescribing. Deprescribing is defined by deprescribing.org as “the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit”. It is effectively a process of regular optimisation and ‘rebalancing’ of prescriptions, to make sure that patients are on the right medications, and the best possible dose of each, to treat their conditions with the fewest side effects.
It is important to note the “planned and supervised” nature of the process. This is not a matter of patients deciding for themselves that they no longer want to take a particular medication, and unilaterally stopping. Instead, it is a process set up jointly by doctors, pharmacists and patients to review patients’ medication and then reduce or change the dosage to reflect changing circumstances. It reflects the fact that individuals’ conditions change over time, and that sometimes a higher initial dose of a medication can be reduced later. It also reflects the use of alternative or additional medications that may render a previous prescription redundant.
It is essential that the process of deprescribing is carefully supervised. Stopping medications can sometimes cause withdrawal symptoms. People may need to be ‘weaned off’ gradually via lower and lower doses over time. Stopping a medication may also affect how other medications work or interact, and not always predictably. Doctors and pharmacists need to be aware of what is happening so that they can support the individual in the event of new symptoms or events.
In the UK, this is done through a process called structured medication reviews. Since October 2020, primary care networks have been required to identify individuals who would benefit from a structured medication review to optimise their medication. These individuals are generally people in care homes, on more than 10 different medications, and particularly taking a medication that is often associated with medication errors, or with addiction. The key in a medication review is to balance the benefit of taking the medication with the risk of doing so — including the risk of errors, side effects and interactions with other drugs.
The benefits of deprescription
Deprescription and medication reviews can have huge benefits to patients. Many of the medications concerned are strong drugs, with a wide range of side effects. People have reported feeling less dizzy, sick and confused — and generally much better — once their medication has been reduced.
However, there are also benefits to health systems, and particularly to the payers, including insurers, individuals or commissioners. Using fewer drugs is, quite simply, cheaper. What’s more, if patients have fewer side effects and feel better, they need fewer healthcare resources over the long term. Done right, deprescribing can be a win for everyone.
