How many megs is considered polypharmacy

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Clinical Pharmacology and therapeutics, 26, — American Journal of Medicine, , The Merck manual of geriatrics, 3rd edn. J Am Geriatr Soc. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. British Journal of Clinical Pharmacology, 63, — The American Journal of Geriatric Pharmacotherapy, 4, 36—41 Medication-related adverse reactions and the elderly: a literature review.

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Eur J Clin Pharmacol, —7. Reporting adverse drug reactions on a geriatric ward: a pilot project. Eur J Clin Pharmacol, — Concealed renal insufficiency and adverse drug reactions in elderly hospitalized patients. Arch Intern Med, —5. The Journal of the American Medical Association, , — Prybys, K. Polypharmacy in the elderly: Clinical challenges in emergency practice: Part 1: Overview, etiology, and drug interactions.

Emergency Medicine Reports, 23 11 , — Adverse drug reaction risk factors in older outpatients. Risk of ADRs among elderly patients with polypharmacy was 2. Low level of education i. In table 4 , we calculated the incidence of ADRs according to the exposure to various drug classes.

The highest incidence was found for antitussives and anti-dopaminergic drugs in our study group. In this prospective cohort study the incidence of ADRs with polypharmacy was found to be In the current study, This is slightly higher than the rates previously reported for geriatric population. We observed a statistically significant association between low levels of education and the concurrent use of non-prescription medicines both before and after adjusting for potential confounders.

With the hope of directing intervention efforts; many associations have been proposed for ADRs among the geriatric population aged 65 years or older since they are mostly prescribed with multiple medications which make them vulnerable to ADRs.

Investigators suggest that longer stay in hospital is one of the probable cause for the occurrence of ADRs in geriatrics and it is defined as an undesirable condition caused by the use of multiple medications [17]. The incidence of This could be due to the difference in the methodological aspects of the study particularly the study population and the self-reporting of ADRs in the follow-ups which was conducted through telephonic calls in the current study.

This probably implies an underestimation of actual occurrence of adverse effects. Another reason for the lower frequency of ADRs observed in our study is probably due to the method of extracting information on the use of complementary and alternative medicines herbal 3. The use of CAM i. One of the strong motivational factors to use CAM is their perceived remedial benefits, and safety profile. However, we can only speculate about the role and benefits of CAM in certain diseases as the role of CAM in chronic diseases is still controversial.

In the current study those elderly who were taking concurrent homeopathic medication were 7 times more at risk of developing ADRs. The probable reason for this high risk of developing ADRs can be due to the fact that many commonly used CAM products have the potential to interfere with the intended action of concomitant prescription medications, which could lead to serious drug interactions and in turn increase the risk of ADRs. Nevertheless, it is important to educate the patients about the risks and benefits of CAM.

Studies are required to determine the impacts of CAM, particularly its impact when used in conjunction with prescribed medicines. It is evident that some drugs such as anticholinergic and antipsychotics can impair the physical and cognitive function in the elderly patients [22]. This implies that the more drugs with these effects that the elderly patients are exposed to number and dose , the poorer will be their quality of life and they will be more prone to ADRs, as evident from the results of the current study that those elderly patients who were positive of polypharmacy had 2.

There are several strengths of our study; a cohort study design was carefully chosen which is ideal in predicting the causal association of exposure with the outcome so inferences can be drawn regarding causality of association between polypharmacy and other factors with the ADRs. We collected data from OPD prescriptions to avoid any miss outs.

The criteria of more than five medications used included only systemic and routinely administered medications. Moreover, there was no loss in following-up in our cohort. However, our study has certain limitations that need to be considered while interpreting the results. This was a hospital based study hence generalizability to public sector settings remain questionable. We followed our subjects for a duration of six weeks only, thus adverse effects arising after this time may not be captured and this might have underestimated our results.

To the best of our knowledge, this is the first Asian study to record the incidence of ADRs in geriatric outpatients with polypharmacy; our study confirms the notion that elderly patients are more likely to experience these adverse reactions as the result of age-related increase in the frequency of drug use, sensitivity to drug effects, and prevalence of predisposing conditions that can increase the frequency and severity of ADRs.

With the current state of health system utilization and health-seeking behavior in Pakistan, it is highly desirable to reduce the divergence by exploring more opportunities for integration of patient safety.

As a way forward this study and its findings may encourage the physicians to implement judicious prescribing. Appropriate educational, managerial or regulatory strategies are needed for evidence based prescribing. It is also important that medications for the elderly patients be reviewed periodically for indication, therapeutic aims, dose, efficacy and probable side effects. Moreover, the benefit and risks of treatment drugs including the impact on functions and quality of life should be discussed with patients and their caregivers.

In conclusion, in this reasonably large hospital based prospective cohort study of geriatrics, the incidence of ADRs due to poly-pharmacy is high. Several factors including low level of education and use of non-prescription medications remain responsible for the high burden. While additional research with more sophisticated design is needed to confirm our findings, our data suggests that a comprehensive strategy for evidence based prescribing must be implemented.

Different mobile health apps offer a lot of options for prescriber and even patient self-assessment DDI checker, medication reminder, refill reminder, medication history tracking and pill identification , although lack of complete information or obstacles in their use can strongly affect their performance Kim et al. Elderly patients are encountered in different settings of care: in primary care community-dwelling or in nursing homes for the management of chronic conditions, and at hospital only for acute conditions.

Nursing home residents typically include older people with a professional support in monitoring healthcare status and helping in adhering to drug therapy. Community dwelling subjects are usually healthier and younger, but they cannot rely on the intensive help of health professionals. As a matter of fact, each setting requires specific analysis of possible ad hoc strategies to be implemented toward supporting patients in avoiding the adverse consequences of DDIs.

The present work has set itself the objective of evaluating what the dimension of clinically relevant drug-drug interactions is in elderly patients out of hospital, by assessing two different sub-populations: community dwelling subjects and residents in nursing homes. The final aim is to identify specific drug-drug interactions on which, in a specific setting, improvement strategies should be implemented.

We conducted an observational study on the geriatric population of the Emilia-Romagna Region as a part of a pharmacovigilance project funded by the Italian Medicines Agency Agenzia Italiana del Farmaco—AIFA and the Emilia Romagna Regional Health Authority for post-marketing activities, aiming at increasing knowledge of ADRs and improving appropriateness of drug prescription.

For each patient, the presence of polypharmacy and specific pairs of drugs with potential interactions drug-drug interactions—DDIs was assessed.

According to the most accepted definitions, we considered polypharmacy as concurrent use of either at least five different medications broad definition or at least 10 different medications narrow definition Gnjidic et al. As for DDIs, by starting from the analysis of several lists published in the literature and mainly referring to a previous approach used by our group Raschi et al.

The list was developed to be as comprehensive as possible, but only manageable interactions were included i. The components in the drug-drug interaction may be a drug class or a single active substance depending on the available evidence.

For the community dwelling cohort, we selected all subjects 65 and older with at least one reimbursed prescription in the first semester The LHA administrative healthcare database contains information on insured subjects unique identification number, sex, and age , on reimbursed prescriptions drug names, trade names, claim date, number of packages dispensed, and Anatomical Therapeutic Chemical Classification System [ATC] code WHO Collaborating Center for Drug Statistics Methodology, and on prescribers identifier numbers and specialty.

Subjects were considered under polypharmacy if they chronically received at least five drugs broad or at least 10 drugs narrow in the analyzed semester. Chronic use was defined as coverage of more than half a semester, i. As regards nursing homes, a sample of residents about was selected for each participant LHA.

For a specific index date, personal data of each patient, administered drug treatments and relevant indications of use were extracted from clinical charts and recorded on a dedicated server. For both polypharmacy and interactions, relevant drugs should be taken in the same day. The study envisaged the use of a dedicated server for data storage and processing.

Descriptive statistics were carried out to describe the baseline characteristics of the study population. The frequency of polypharmacy, as well as each potential interaction, was obtained for each setting of care from the percentage ratio between patients exposed to polypharmacy, or each specific interaction respectively, and the total number of patients in the cohort.

Pseudonymized administrative data can be used without a specific written informed consent when patient information is collected for healthcare management and healthcare quality evaluation and improvement according to art.

In the present study, data were pseudonymized by each single LHA, analyzed, and aggregated at the local level. Aggregated data were then shared among participants to the project in order to obtain overall frequencies of each indicator described above. The nursing home cohort included 3, institutionalized patients: The outpatient cohort included , subjects i. In nursing homes, a total of pairs of interacting drugs were analyzed, resulting in a frequency of Among community-dwelling subjects the interactions including only reimbursed medicines amounted to If from the list of interactions analyzed in nursing homes, we exclude the 40 pairs of interactions mainly formed by benzodiazepines that cannot be studied among the dwelling communities not reimbursed medicines , this risk of exposure decreases to TABLE 2.

Prevalence of potential drug-drug Interactions by therapeutic drug class and individual agents. The most frequent co-prescription of potentially interacting drugs in nursing homes was represented by antidepressants—anxiolytics Classes of drugs most involved in potential interactions were antidepressants, anxiolytics and vitamin K antagonists for nursing home setting, and NSAIDs, antidiabetics, SSRIs, and calcium channel blockers for the community-dwelling population.

No correlation of prevalence of DDIs and polypharmacy between nursing homes and community dwelling setting within the same LHA was found. To the best of our knowledge, this is the first Italian population-based study providing an overall picture of polypharmacy and DDIs in a sample of the Italian geriatric population, by monitoring both community-dwelling and nursing-home institutionalized subjects.

The two mentioned populations differ in health status and level of care: the former live at home, refer mainly to general practitioner and in some cases are supported by relatives or caregivers, while residents in nursing homes have more complex clinical profiles and a more intensive level of care.

This last aspect allows closer monitoring of drug effect and treatment adherence, but probably induces the use of a greater number of drug treatments, as documented by our findings: i. The number of concomitant drugs is considered the most important predictive factor of ADR by the literature with a linear relationship with the risk of adverse events Viktil et al.

Pharmacodynamic mechanisms have been identified as the main underlying pharmacological basis and bleeding and dysglycemia are potentially the most frequent ADRs. A number of interventions toward reduction of psychotropic medicines in this setting are described in the literature: from sensitization of caregivers on risks of ADRs in order to reduce new treatments e. As many as It is noteworthy that 1. Distribution of the numbers of reimbursed drugs holding various active substances dispensed to patients according to prescriptions in Poland in Note: Numbers calculated for the drugs dispensed within six months from the first dispensation in the calendar year.

Prevalence of polypharmacy calculated according to dispensation of the reimbursed drugs within six months from the first dispensation within a calendar year and its distribution across age groups in and is presented in Figure 2. Polypharmacy defined that way was observed in It is worth emphasizing that the older the age group, the higher was the prevalence of polypharmacy, reaching its highest value of Altogether, among those aged over 65 years, prevalence of polypharmacy was On the other hand, among those aged below 20 years, prevalence of polypharmacy was 0.

Prevalence of polypharmacy across age groups in Poland in and Note: Polypharmacy defined as dispensation of reimbursed drugs holding five or more active substances within six months from the first dispensation in the calendar year.

Table 1 presents the number of patients by age group together with the number of active substances dispensed in , as by the two halves of the year. The data relate to prescriptions filled in the above time period, for both drugs reimbursed and non-reimbursed. In the first half of , in Poland there were almost 8. In this group, 4. In the second half of the year, there were slightly more i. Prevalence of polypharmacy, defined as dispensation of five or more various drugs including both reimbursed and non-reimbursed medications within a half-year period, was Among those aged over 65 years, the relevant figures were TABLE 1.

Age distribution of individuals dispensed various number of drugs holding various active substances according to prescriptions for both reimbursed and non-reimbursed drugs in half-year periods of in Poland.

It is worth noting that a large group of individuals were dispensed as many as ten or more active substances in prescription drugs, which is often defined as extreme polypharmacy. In the first half of , there were 2. People aged over 65 years in the first half of the year accounted for Figure 3 shows the age structure of patients depending on the number of various drugs dispensed in What is noteworthy is the fact that, along with the number of drugs dispensed, the percentage of elderly people increased up to Overall, among those who were dispensed five or more drugs, older adults aged 65 years or more accounted for Age structure of individuals dispensed various number of drugs holding various active substances according to prescriptions for both reimbursed and non-reimbursed drugs in in Poland.

Using real-world data, we have found high prevalence of polypharmacy reaching This number rose up to These findings correspond with results of studies performed in other countries, despite several differences in methodology e. A study analyzing data from pharmacy claims of 1. A study in a population of one of the Japanese prefectures revealed prevalence of polypharmacy defined as prescribing of six or more drugs per month at the level of In fact, studies smaller in data size observed similar results.

Polypharmacy was observed among Out of , Scottish adults studied, Not surprisingly, we have found prevalence of polypharmacy increasing with age, with relevant percentage rates exceeding one third in the age group 65—79 years, and reaching Altogether, for the entire group of elderly citizens i. However, relevant numbers rose to nearly two thirds for the elderly when analyzing both reimbursed and non-reimbursed drugs In this case our results are again similar to those obtained in other countries, proving polypharmacy particularly prevalent in the elderly.

In Italy, polypharmacy was observed in Polypharmacy defined as use of five or more medications in the last two weeks , and excessive polypharmacy defined as use of ten or more medications in the last two weeks was found in In a recent European study, polypharmacy was identified in In Poland, this ratio was already shown to be higher and amounted to approximately It is noteworthy that in other age groups, e.

A recent scoping review proved high prevalence of polypharmacy in pediatric patients, ranging from 0. However, that review defined pediatric polypharmacy as taking more than one medication Feinstein et al. An important clinical implication of our study is that polypharmacy is highly prevalent in Poland. Since the elderly were found to represent a majority of patients exposed to polypharmacy, particular attention should be focused on these patients.

However, polypharmacy was proven to be a problem not limited to the elderly only. Being aware of this fact, clinicians should pay much more attention to the issue of polypharmacy across all age groups. A recent WHO report on polypharmacy underpins this problem, and urges different countries to take early priority action to protect patients from harmful effects of polypharmacy by implementing dedicated programs World Health Organization, Unfortunately, a search for polypharmacy management programs, undertaken recently within the framework of the SIMPATHY project, revealed existence of such dedicated initiatives in five out of nine assessed countries only McIntosh et al.

Moreover, no official program of that kind was identified in Poland Stewart et al. Under these circumstances, a comprehensive, policy-driven, and evidence-based approach to management of inappropriate polypharmacy which was introduced in Scotland is particularly interesting since it may serve as an example of good practice Wilson et al. Another crucial issue is, however, reaching individual prescribers as studies in many countries proved high variability of polypharmacy prevalence across primary care centres Franchi et al.

The WHO report provides several practical tips on how to reduce the burden of polypharmacy problem, and showcases several European projects focused on obtaining the goal. In particular, the WHO report encourages use of medication reviews, i. This entails detecting drug-related problems and recommending interventions.

Additionally, it advocates the concept of deprescribing, i. World Health Organization, So far, several clinical algorithms and guidelines have been published in order to reduce inappropriate prescribing and manage polypharmacy Muth et al. A certain limitation of this study is that we could not seek for possible correlations between the number of conditions a particular patient was diagnosed with, their characteristics, or formally diagnosed multimorbidity, and the individual exposure to polypharmacy.

Similarly, we could neither investigate the rationales for identified polypharmacy cases, nor dichotomize them into appropriate and inappropriate ones. It was not possible due to the characteristics of data that were available for our analysis, i.

To overcome these limitations, an access to full medical history of each patient would be necessary. Unfortunately, a nationwide electronic health record system has not been launched yet in Poland, which makes comparisons between conditions diagnosed and drugs prescribed and dispensed for individuals practically impossible.

Thus, we may only hypothesize that multimorbidity must have had an effect on polypharmacy prevalence in the studied Polish population. Numerous data show that the greater the number of conditions a patient is diagnosed with, the higher is the probability of polypharmacy Slabaugh et al. This, in fact, shall be taken into consideration while interpreting the study results, as adherence is a major factor contributing to the number of drugs and individual doses that the patient uses.

The actual degree of drug use is modified by patient adherence, which varies from over- to underuse of prescribed drugs. Fortunately, the data analyzed by us, i.

Of course, secondary non-adherence most often leads to underuse of drugs. However, not only the opposite might be true, but also postponed doses taken cumulatively may expose a patient to increased risk of negative consequences of polypharmacy, e.

An obvious limitation of our study comes with the fact that the scope of the analyzed drugs was narrowed down to prescription drugs only, and as in the case of results, only reimbursed drugs were included. In fact, polypharmacy is a problem which might be caused by various sort of remedies, including non-reimbursed prescription drugs, as well as over-the-counter OTC drugs and dietary supplements which are often overused.

On the other hand, it is worth emphasizing that in the case of an analysis on drug intake by patients, focused on such aspects as adherence or polypharmacy levels, results based on administrative data are considered a reliable source of information, as compared to surveys or patient reports, which are subject to e. Finally, it should be kept in mind that our study was based on a nationwide dispensation database, and only a few drug groups of minor importance were excluded from analysis for practical reasons.