Accumulation of Good Intentions: How Individual Practice Guidelines Lead to Polypharmacy in the Treatment of Patients with Polytrauma

Abstract

Polytrauma clinical triad (PCT) is the comorbid occurrence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain after trauma. No clinical practice guidelines for postacute care of patients with PCT currently exist; instead, clinical practice guidelines have been published for the three conditions (TBI, PTSD, and pain) as distinct clinical entities. Using multiple, individual practice guidelines for a patient with PCT may lead to unintended prescription of multiple and potentially adversely interacting medications (ie, polypharmacy). Polypharmacy, especially that which includes central nervous system-acting medications, may lead to overdose, suicidality, and chronic symptomatology. Current individual guidelines for each condition of PCT do not address how to coordinate care for the polytraumatic diagnosis. The purpose of this Practice Management piece is to describe the unintended consequences of polypharmacy in patients with PCT and to discuss mitigation approaches including rational prescribing, nonpharmacologic alternatives, and interdisciplinary coordination.

Medication utilization in traumatic brain injury patients—insights from a population-based matched cohort study

“…TBI patients may experience a variety of physical health problems after their injury, including motor impairment, chronic pain, hormonal imbalance, cardiovascular conditions, digestive issues, and sleep disturbances ( 1–8 ), that may lead to an overall decline in function. Management of these problems could lead to the unintended use of multiple medications due to separate treatment settings and guidelines ( 34 ). However, polypharmacy is of concern as it may affect medication effectiveness and safety, raise the risk of drug–drug interactions, and increase mortality after the TBI ( 35–37 ).…”

Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury

“…Older veterans appear to be at a particular risk for adverse outcomes associated with polypharmacy, including morbidity, mortality, and suicide ( 5 , 19 , 32 ). Moreover, polypharmacy itself has been repeatedly associated with a greater risk for suicide-related behaviors ( 4 , 19 , 33 ). Similar to the existing literature on CNS polypharmacy among older adults, post-911 veterans were also susceptible to severe adverse reactions secondary to having multiple CNS-acting medications on hand to manage co-existing chronic conditions.…”

“…TBI, however, is often followed by common mental and physical health symptoms, making it difficult to isolate TBI-related sequelae and symptoms from other causes. Given this complicated clinical picture, patients with a history of mTBI may present with an extensive medical history that includes treatment with multiple (sometimes concurrent) medications acting on the CNS (i.e., CNS polypharmacy) which can further exacerbate symptomology with medication-induced side effects ( 4 , 9 , 10 ).…”

Effects of intranasal (S)-ketamine on Veterans with co-morbid treatment-resistant depression and PTSD: A retrospective case series

“…4 , 5 Response rates to selective serotonin reuptake inhibitors (SSRIs) in patients with PTSD rarely exceed 60% and only about 20–30% achieve complete remission of their symptoms, 6 , 7 resulting in many patients being prescribed complex pharmacologic regimens. 7 , 8 , 9 Further complicating PTSD treatment is comorbidity with depression. Epidemiological studies indicate more than half of US Military Veterans with PTSD also meet criteria for Major Depressive Disorder (MDD), 10 , 11 which can make adequate treatment of both conditions more challenging.…”