Systematic Approach to Managing Polypharmacy

Definition and Impact of Polypharmacy

Polypharmacy is commonly defined as the concurrent use of 5 or more medications, including over-the-counter, prescription, traditional, and complementary medicines, and is associated with serious adverse outcomes, according to the American Geriatrics Society 2
The use of multiple medications is linked to drug-drug interactions and drug toxicity, falls with injury and increased mortality, delirium and cognitive impairment, medication nonadherence, increased hospitalizations and healthcare costs, and functional decline, as reported by the Mayo Clinic Proceedings 1

Creating an accurate medication list at every visit, including all prescriptions, over-the-counter medications, and supplements, is crucial for identifying discontinued, missing, or incorrectly taken medications, as recommended by the Mayo Clinic Proceedings 4
The American College of Clinical Pharmacy suggests using validated tools like the Morisky Medication Adherence Scale to identify adherence barriers and reviewing pill boxes, medication bottles, and fill dates to assess adherence 4

The National Comprehensive Cancer Network recommends using interaction databases to identify high-risk combinations, paying particular attention to QT prolongation risks, anticoagulant interactions and bleeding risk, serotonin syndrome potential, and medications requiring cytochrome P450 metabolism 5
The American Geriatrics Society advises identifying medications that may worsen existing conditions, such as NSAIDs in heart failure, chronic kidney disease, or hypertension, and sulfonylureas in chronic kidney disease 4

The Mayo Clinic Proceedings suggests looking for duplicate therapies or medications with additive side effects and assessing for prescribing cascades, and considering whether all medications still align with current treatment goals 1
The American Geriatrics Society recommends using validated tools to identify potentially inappropriate medications, such as the Beers Criteria, STOPP, and START, and paying special attention to high-risk drug classes, including opioids, benzodiazepines, and other sedatives 2

The American College of Clinical Pharmacy defines deprescribing as the process of reducing drug dose, weaning off, discontinuing, or switching to safer alternatives when potential harm outweighs benefit, and recommends best practices, including education about risks for patients and families, agreement by patients, families, and care teams, and gradual tapering of high-risk medications 2

The American Geriatrics Society recommends adjusting doses based on declining kidney function using laboratory-reported clearance estimates and considering functional and cognitive status, not just chronological age, when making medication decisions 3
The Kidney International journal suggests that medication reconciliation is critical during care transitions and communication between providers is essential to prevent inappropriate prescriptions 6

The Mayo Clinic Proceedings recommends utilizing clinical pharmacists for medication reviews when available and coordinating care among multiple prescribers to prevent duplication 4
The Kidney International journal suggests considering computerized alerts and decision support tools to improve medication management 6

The Kidney International journal warns against focusing only on the number of medications rather than appropriateness and failing to consider patient preferences and treatment goals 6
The Mayo Clinic Proceedings advises against abruptly discontinuing medications without proper tapering and overlooking non-prescription medications and supplements 1