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PubMed1996

Polypharmacy in bipolar I disorder.

There are currently three mood stabilizers available for the maintenance treatment of patients with bipolar I disorder: lithium, valproate, and carbamazepine. Unfortunately, monotherapy with each of these conventional agents often fails. To improve outcome, clinicians utilize polypharmacy. Although the efficacy of this practice is largely unknown, because of the lack of controlled studies, data from the United States and Europe indicate polypharmacy is the rule rather than the exception. The few controlled trials that have been conducted indicate that (1) the specific combination of lithium plus imipramine provides no advantage over lithium monotherapy (notwithstanding the inadequacy of lithium monotherapy); (2) the specific combination of lithium and the depot neuroleptic flupenthixol provides no advantage over lithium monotherapy; and (3) the combination of lithium plus carbamazepine may be as effective as lithium plus haloperidol for acute and continuation treatment. Most of the literature on polypharmacy consists of case reports, retrospective chart reviews, and open-label prospective studies, and describes the use of numerous combinations of medications, including lithium plus valproate, lithium plus carbamazepine, and valproate plus carbamazepine. Preliminary findings suggest these combinations may be effective, and that clozapine and high-dose levothyroxine may each be useful as well when combined with other drugs. Further research is necessary to formally evaluate whether these drug combinations are more effective than monotherapy. Until such studies are completed, certain general principles regarding side effects, pharmacodynamics, and pharmacokinetics should be kept in mind when prescribing two or more medications concurrently.

Bipolar Disorder↗

PubMed2004

Improvement in seizure control and quality of life in medically refractory epilepsy patients converted from polypharmacy to monotherapy.

In a retrospective chart review, we identified 35 patients with medically refractory epilepsy (MRE) who had been converted from polypharmacy to monotherapy and maintained on monotherapy for at least 12 months. None of the 35 patients had worsening of their seizure frequency after the conversion to monotherapy. Fourteen of the 35 patients (40%) became seizure-free. Nine of 35 patients (26%) had a 50% reduction in seizure frequency. Five of 35 patients (14%) had a 75% reduction in seizure frequency. Twenty-eight (80%) of 35 patients participated in a quality-of-life questionnaire. Quality of life was rated as better on monotherapy as compared with polypharmacy in a number of domains: memory loss, concern over medication long-term effects, difficulty in taking the medications, trouble with leisure time activities, and overall state of health. This improvement reached statistical significance. Conversion to monotherapy in patients with MRE may be successful in achieving a reduction in seizure frequency and an improvement in quality-of-life parameters. A prospective, randomized trial is necessary to validate these findings.

Adult↗

PubMed2006

Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems.

AIM: To investigate whether polypharmacy defined as a definite number of drugs is a suitable indicator for describing the risk of occurrence of drug-related problems (DRPs) in a hospital setting. METHODS: Patients admitted to six internal medicine and two rheumatology departments in five hospitals were consecutively included and followed during the hospital stay, with particular attention to medication and DRPs. Comparisons were made between patients admitted with five or more drugs and with less than five drugs. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions. RESULTS: Of a total of 827 patients, 391 (47%) used five or more drugs on admission. Patients admitted with five or more and less than five drugs were prescribed the same number of drugs after admission: 4.1 vs. 3.9 drugs [P = 0.4, 95% confidence interval (CI) - 0.57, 0.23], respectively. The proportion of drugs used on admission which was associated with DRPs was similar in the patient group admitted with five or more drugs and in those admitted with less than five drugs. The number of DRPs per patient increased approximately linearly with the increase in number of drugs used; one unit increase in number of drugs yielded a 8.6% increase in the number of DRPs (95% CI 1.07, 1.10). CONCLUSION: The number of DRPs per patient was linearly related to the number of drugs used on admission. To set a strict cut-off to identify polypharmacy and declare that using more than this number of drugs represents a potential risk for occurrence of DRPs, is of limited value when assessing DRPs in a clinical setting.

Aged↗

PubMed2006

Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial.

OBJECTIVE: To investigate the effects of compliance and periodic telephone counselling by a pharmacist on mortality in patients receiving polypharmacy. DESIGN: Two year randomised controlled trial. SETTING: Hospital medical clinic. PARTICIPANTS: 502 of 1011 patients receiving five or more drugs for chronic disease found to be non-compliant at the screening visit were invited for randomisation to either the telephone counselling group (n = 219) or control group (n = 223) at enrollment 12-16 weeks later. MAIN OUTCOME MEASURES: Primary outcome was all cause mortality in randomised patients. Associations between compliance and mortality in the entire cohort of 1011 patients were also examined. Patients were defined as compliant with a drug if they took 80-120% of the prescribed daily dose. To calculate a compliance score for the whole treatment regimen, the number of drugs that the patient was fully compliant with was divided by the total number of prescribed drugs and expressed as a percentage. Only patients who complied with all recommended drugs were considered compliant (100% score). RESULTS: 60 of the 502 eligible patients defaulted and only 442 patients were randomised. After two years, 31 (52%) of the defaulters had died, 38 (17%) of the control group had died, and 25 (11%) of the intervention group had died. After adjustment for confounders, telephone counselling was associated with a 41% reduction in the risk of death (relative risk 0.59, 95% confidence interval 0.35 to 0.97; P = 0.039). The number needed to treat to prevent one death at two years was 16. Other predictors included old age, living alone, rate of admission to hospital, compliance score, number of drugs for chronic disease, and non-treatment with lipid lowering drugs at screening visit. In the cohort of 1011 patients, the adjusted relative risk for death was 1.61 (1.05 to 2.48; P = 0.029) and 2.87 (1.80 to 2.57; P < 0.001) in patients with compliance scores of 34-66% and 0-33%, respectively, compared with those who had a compliance score of 67% or more. CONCLUSION: In patients receiving polypharmacy, poor compliance was associated with increased mortality. Periodic telephone counselling by a pharmacist improved compliance and reduced mortality. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register: SRCTN48076318.

Adult↗

PubMed2001

A prediction model for polypharmacy: are older, educated women more susceptible to an adverse drug event?

INTRODUCTION: This study attempts to account for variation in the number of prescription medications concurrently consumed in geriatric populations. METHODS: Data were selected from The National Health and Nutrition Examination Survey, III, 1988-1994 (NHANES III), Adult Household Questionnaire, a complex, multistage, clustered sampling of civilian, non-institutionalized populations, which included a volunteer sample of 5,249 individuals aged 65 and older who participated in NHANES III survey, representing four broad geographic regions and twelve states. RESULTS: Age, income, and educational level accounted for nine percent of the variation in the number of prescription medications concurrently taken (p < 0.0001); though non-significant, there were gender differences regarding polypharmacy; in addition, there were significant differences with respect to educational levels by region and age by region (p < 0.05). CONCLUSIONS: Educational level accounted for the most variation in polypharmacy. Women, on average, consumed more prescription medications than men. Older, more educated women may be most likely to engage in polypharmaceutical consumption, suggesting a greater likelihood of an adverse drug event.

Aged↗

PubMedDate not supplied

Pharmacotherapy consultation on polypharmacy patients in ambulatory care.

OBJECTIVE: To investigate actual cost and adverse effect outcomes associated with a phamacotherapy consultation in ambulatory care patients receiving polypharmacy. METHODS: Patients receiving five or more chronic medications were randomized to receive pharmacotherapy consultation or usual medical care. Outcomes measured were changes in drug costs, medical costs, and drug-related symptoms six months after the consultation. Data were analyzed with unpaired Student's t-test for continuous data. Chi2 Analysis was used for categorical data. Patients and physicians were surveyed about their perceptions of the consultations after the study period. RESULTS: Drug and medical costs did not differ before and after the consultation. More patients in the consultation group had adverse symptom scores improve by two or more points, and fewer had symptom scores worsen by two or more points than in the control group. Seventy percent of patients and 76% of physicians believed that the consult was beneficial. CONCLUSIONS: Polypharmacy patients are the most likely to have drug-related problems and require intervention. Of all the interventions performed in this study, 73% of the original problems were recognized only through a patient interview, suggesting that an interpersonal relationship remains critical to the provision of pharmaceutical care. Although patients and physicians see intuitive value in pharmaceutical care, pharmacists need to exert more energy in the direction of marketing the profession. Finally, there are numerous difficulties in measuring the benefits of these interventions, possibly making broad-based interventions in complicated patients too difficult to assess accurately. Future studies should focus on patients with limited, specific problems or on interventions with narrow goals.

Ambulatory Care↗

PubMed2005

Pharmacist response to alerts generated from Medicaid pharmacy claims in a long-term care setting: results from the North Carolina polypharmacy initiative.

OBJECTIVE: In response to burgeoning drug costs, North Carolina (NC) Medicaid encouraged pharmacists and prescribers to develop collaborative programs to reduce drug expenditures. One of these programs, the North Carolina Polypharmacy Initiative, was a focused drug therapy management intervention aimed at reducing polypharmacy in nursing homes. This intervention targeted patients with more than 18 prescription fills in 90 days, beginning in November 2002. These patients were believed to have a high likelihood of experiencing potential drug therapy problems (PDTPs). Consultant pharmacists were asked to utilize profiles displaying alerts generated from pharmacy claims to guide interventions in addition to usual-care drug regimen reviews. The pharmacists documented their reviews, recommendations, and resulting changes in drug therapy. Our objectives were to determine (1) the persistence of PDTP alerts following interventions by consultant pharmacists and (2) the impact of these interventions on patient drug costs from a payer perspective. METHODS: A before-after study with comparison group design was used. Medicaid prescription claims data were compared for the 90-day periods prior to the intervention (June-August 2002) and following the intervention (March-June 2003). The 90-day post-intervention period allowed for 2 to 3 follow-up prescriptions and reduced the drop-out rate. The 5 categories of potential problem alerts included potentially inappropriate medications (Beers criteria), substitution opportunity for a lower-cost drug, 16 drugs or drug classes with specific quality improvement opportunities (Clinical Initiatives list), therapeutic duplication, and length of drug therapy evaluation. RESULTS: A total of 253 nursing homes, involving 110 consultant pharmacists and 6,344 patients, were in the intervention arm, with 5,160 patients (81.3%) remaining at the end of the follow-up period. At baseline, study-group patients used an average of 9.7 prescriptions per month, costing the NC Medicaid program 517 US dollars per patient per month (PPPM). There were 6,360 recommendations offered for 3,400 patients, or an average of 1.87 recommendations per patient. Physicians concurred with 59.8% (3,801 of 6,360) of all recommendations to change drug therapy, about half involving a switch to a lower-cost drug. Two of 5 alert categories had significant (P <0.01) reductions in alert persistence: -10.8% for the study group versus -0.7% for the comparison group for the Clinical Initiatives list and -29.7% for the study group versus -14.1% in the comparison group for the drug substitution opportunity. Median drug costs per patient in the study group decreased by 12.14 US dollars (-0.92%), from 1,329.46 US dollars to 1,317.32 US dollars, and increased in the comparison group by 44.98 US dollars (3.35%), from 1,341.25 US dollars to 1,386.23 US dollars, creating a relative cost reduction of 57.12 US dollars per patient in the 3-month follow-up period, or 19.04 US dollars PPPM. CONCLUSION: A supplemental program of medication reviews for nursing home patients targeted by high drug utilization resulted in a reduction in the persistence of PDTP alerts and was cost beneficial based solely on drug cost savings. This intervention may be a model for future medication therapy management services provided by prescription drug plans under Medicare Part D for patients in long-term-care settings and possibly ambulatory patients.

Aged↗

PubMed2001

Is it possible to reduce polypharmacy in the elderly? A randomised, controlled trial.

OBJECTIVE: The present trial was originally designed to investigate the effectiveness of comprehensive day hospital care in chronically ill elderly patients. Another aim, reported here, was to investigate to what extent it is possible to reduce polypharmacy and simplify drug regimens during the short term tight control conditions of day hospital care. PATIENTS: All home care patients (n = 174, mean age 77 years) in a rural area, Kirkkonummi-Siuntio, in Finland. DESIGN AND SETTING: Patients were randomised into 2 groups, one of which was offered a 2-month period of day hospital care. Patients assumed to be noncompliant (because they did not want day hospital care) were also included in order to see the effect of intervention in 'real-life'. The medications of all participants were reviewed and counted during an in-home assessment by a home nurse. In the intervention group, necessary revisions (dose reduction, discontinuation, possible additions) were performed through the tight monitoring of day hospital care and in co-operation with the patient. The patients were followed up for 10 months after completion of the intervention programme. OUTCOME MEASURES: Number of prescribed medications, number of over-the-counter (OTC) drugs, number of doses taken daily by the patients. Assessments were performed at baseline, and after 2, 5 and 12 months. RESULTS: There were no significant changes in the number of prescribed medications. In patients in day hospital care, the number of doses was reduced significantly (p = 0.02) during the 2-month day hospital period compared with the control group. However, the patients compensated for the reductions by increasing the use of OTC drugs during the day hospital period (p = 0.05). In addition, only 3 months after the trial, the number of drugs had already returned to the baseline level. CONCLUSIONS: In real life it seems to be difficult to reduce polypharmacy in the elderly. Some drug reductions may be achieved with tight control under trial conditions, but when the intervention ceases the number of drugs used soon returns to its earlier level.

Activities of Daily Living↗

PubMed1999

[Drugs and polypharmacy].

The author deals with the causes of increasing polypharmacy in the Czech Republic. He discusses all problems concerned with treatment and analyzes attitudes of drug manufacturers, physicians, patients, the state and its health policy. He mentions also possible ways how to reduce polypharmacy. Attention is drawn to the role of the pharmacist in conjunction with extension of the spectrtum of drugs which can be purchased without restriction.

Czech Republic↗

PubMed1993

Polypharmacy: the cure becomes the disease.

Polypharmacy occurs when a medical regimen includes at least one unnecessary medication. Factors that contribute to this problem include: patient characteristics of increasing age, multiple medical problems, therapy expectations, and decisions to self-treat; physician factors such as excessive prescribing; and system problems of multiple providers and lack of a coordinating provider. Complications include increased adverse drug reactions and noncompliance, which can lead to increased hospitalization and associated costs. Polypharmacy can be avoided by patient education and sharing the decisions for making the treatment goals and plan. The medication regimen can be simplified by eliminating pharmacologic duplication, decreasing dosing frequency, and regular review of the drug regimen. The goal should be to prescribe the least complex drug regimen for the patient as possible, while considering the medical problems and symptoms and the cost of therapy.

Aged↗

PubMed1996

A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.

PURPOSE: To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians. PATIENTS AND METHODS: Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity. RESULTS: Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001). CONCLUSIONS: This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

Aged↗

PubMed2002

Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas.

BACKGROUND: Heart failure (HF) is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the extent of these problems in the very elderly. METHODS: A retrospective study of 116 patients (median age 86; range 65-98) with an established diagnosis of HF during their hospital admission. MAIN OUTCOME MEASURES: the accuracy of diagnosis of heart failure according to the European Society of Cardiology (ESC) definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment. RESULTS: The specificities of clinical signs, chest X-rays and abnormal ECGs for heart failure (ESC definition) were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities included chest disease (30%), incontinence (29%), cerebrovascular disease (26%), musculoskeletal problems (41%). Barthel (activities of daily living) score was < or = 16/20 in 35%. Mental state questionnaire (MSQ) score was < or =7/10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance. CONCLUSION: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment.

Aged↗

PubMed2000

Patient satisfaction with polypharmacy reduction in chronic epileptics.

The effects of polypharmacy reduction on patient satisfaction and subjective seizure severity were assessed prospectively in adult out-patients with chronic epilepsy using Japanese versions of the Side effects and Life Satisfaction (SEALS) and the Seizure Severity Questionnaires (SSQ). Antiepileptic drugs (AED) were withdrawn using a 1-year reduction schedule. The SSQ score was not aggravated and total SEALS score improved significantly. Moreover, temper subscore was also improved in the sedative AED reduction group. Similar to previous studies from the physician's viewpoint, the present study confirms that from the perspective of the patient, polypharmacy reduction, especially withdrawal of sedative AED, has a favorable effect on patient satisfaction.

Adult↗

PubMed1999

Migraine polypharmacy and the tolerability of sumatriptan: a large-scale, prospective study.

Polypharmacy (the prescription of more than one therapy for a single patient) and subcutaneous (s.c.) sumatriptan tolerability were prospectively studied in 12,339 migraineurs, each followed for up to 1 year. Inclusion/exclusion criteria were minimal and mirrored United States Imitrex labeling. Drug usage and compliance monitoring were automatically interfaced with prescription refill. Concomitant drugs were used by 79% of patients, with analgesics, antidepressants, and sedatives used most commonly. No adverse interactions between sumatriptan and neurological drugs were found, possibly reflecting relative inability of the former to cross the blood-brain barrier. No difference in cardiovascular adverse events was associated with oral contraceptive use, which was more common than expected. No other drug class influenced adverse event probability, although sample sizes for these comparisons was sometimes <400 patients. This study confirms the prevalence of polypharmacy in migraine, identifies the drugs used, and concludes that, on a population basis, the tolerability of s.c. sumatriptan, when used according to labeled instructions, is unaffected by these concomitant drugs.

Adolescent↗

PubMed2003

Reducing the dose of antipsychotic medications for those who had been treated with high-dose antipsychotic polypharmacy: an open study of dose reduction for chronic schizophrenia.

Antipsychotic medications are often used at higher than the recommended dose and sometimes in a combination regimen to treat schizophrenia. However, in general, high-dose therapies have been abandoned in recent clinical studies. In this study, dose reduction of antipsychotic medication was implemented for patients with chronic schizophrenia, most of whom (81%) had been treated with an antipsychotic high-dose polypharmacy regimen consisting of more than 1000 mg/day in total amount. The results show that merely reducing the amount of antipsychotic led to favourable outcome in 23 out of 41 cases (56%), with another 13 cases (32%) showing no change. Dose reduction ended in failure in only five subjects (12%). Overall, the amount as well as the number of antipsychotic medications was significantly reduced from 1984 mg to 812 mg per day (reductions of 59% and from 3.6 to 2.2, respectively; both P<0.0001). The Global Assessment of Functioning scale improved from 30.6 to 37.2, which reached significance (P<0.001). Accordingly, the Severity of Illness improved from 4.7 to 4.2, and was also significant (P<0.01). Dose reduction is an encouraging strategy to consider for those patients with schizophrenia who have chronically been treated with high-dose antipsychotic polypharmacy, even if judged unavoidable in the past.

Adolescent↗

PubMed1995

Reducing polypharmacy in extended care.

In this 5-year prospective study, we determined the feasibility of reducing polypharmacy in a long-term care institution by a systematic review of the pharmacy records. At 6-month intervals, the computer printout of all medications prescribed to patients in a 550-bed institution was reviewed. After patients taking more than 10 different drugs were identified, their physician was notified and was asked to review their medications according to specific guidelines. The number of patients taking 10 or more medications was reduced from 67, when the program was started, to 9. The average number of medications per patient was reduced from 5.5 to 4.6. This program reduced the prevalence of polypharmacy and had long-lasting effects on the physicians' prescribing habits. We also believe it led to improved patient care by reducing the potential for drug interactions and to cost savings for the pharmacy.

Aged↗

PubMed2005

Antipsychotic polypharmacy: is there evidence for its use?

Antipsychotic polypharmacy occurs frequently in clinical practice; however, there is a lack of controlled clinical studies testing the efficacy of the combinations used. The purpose of this literature review was to examine studies and other reports that have assessed the incremental benefits and deficits of combination antipsychotic therapy versus monotherapy. A PUBMED search covering a 26-year period from 1976 to 2002 was conducted. The search was limited to clinical trials, case series, and reports. Fifty-two reports were identified that systematically assessed the efficacy of combination therapy as opposed to monotherapy: 4 double-blind studies, 13 open-label clinical trials, and 35 case reports. Only one open-label trial and 2 case reports met the design criteria of having trials of each medication and the combination in the same patients and using some type of standardized assessment to evaluate outcome. The most frequent combination was clozapine-risperidone. Of the clinical trials, 75% (3/4) of the double-blind studies and 69% (9/13) of the open-label trials found that combination therapy was effective in reducing symptoms, while 37% (13/35) of case reports documented an overall positive outcome. Currently, the clinical practice of antipsychotic polypharmacy is not evidence-based; however, there is also no evidence against its use. Expanded systematic research to assess this clinical practice is needed.

Antipsychotic Agents↗

PubMed1977

Incidence of polypharmacy in a long-term care facility.

The incidence of polypharmacy was investigated in a 200-bed long-term care facility. One hundred residents were drawn at random for the study. The average number of drugs prescribed per patient was 3.33, and the average number of pills was 6.34 daily. The most frequently prescribed drugs were the analgesics, followed in order by antihypertensive agents, cardiotonic preparations and antimicrobials. The literature is reviewed with respect to the incidence, causes and end-results of polypharmacy. It is recommended that long-term care facilities develop enlightened and aggressive pharmacy committees to monitor and evaluate drug use routinely in an institutional setting.

Analgesics↗