Polypharmacy or medication washout: an old tool revisited

Abstract

There has been a rapid increase in the use of polypharmacy in psychiatry possibly due to the introduction of newer drugs, greater availability of these newer drugs, excessive confidence in clinical trial results, widespread prescribing of psychotropic medications by primary care, and pressure to augment with additional medications for unresolved side effects or greater efficacy. Even the new generation of medications may not hold significant advantages over older drugs. In fact, there may be additional safety risks with polypharmacy being so widespread. Washout, as a clinical tool, is rarely done in medication management today. Studies have shown that augmenting therapy with additional medications resulted in 9.1%–34.1% dropouts due to intolerance of the augmentation, whereas studies of medication washout demonstrated only 5.9%–7.8% intolerance to the washout procedure. These perils justify reconsideration of medication washout before deciding on augmentation. There are unwarranted fears and resistance in the medical community toward medication washout, especially at the moment a physician is trying to decide whether to washout or add more medications to the treatment regimen. However, medication washout provides unique benefits to the physician: it establishes a new baseline of the disorder, helps identify medication efficacy from their adverse effects, and provides clarity of diagnosis and potential reduction of drug treatments, drug interactions, and costs. It may also reduce overall adverse events, not to mention a potential to reduce liability. After washout, physicians may be able to select the appropriate polypharmacy more effectively and safely, if necessary. Washout, while not for every patient, may be an effective tool for physicians who need to decide on whether to add potentially risky polypharmacy for a given patient. The risks of washout may, in some cases, be lower and the benefits may be clearly helpful for diagnosis, understanding medication effects, the doctor/patient relationship, and safer use of polypharmacy if indicated.

Prescribing in schizophrenia and psychosis: Increasing polypharmacy over time

“…From the baseline medication data reported in the Clinical Antipsychotic Trials of Intervention Effectiveness study, rates of polypharmacy were also high with 6% taking two antipsychotics and 38% taking combination antipsychotic and antidepressant (Chakos et al, ). Reasons for the increasing prevalence of psychotropic polypharmacy are multifactorial and include increased numbers of available medications, widespread prescribing of psychotropics within primary care, decision to augment with additional medication in the face of ongoing symptoms, and at times a prescriber reluctance to withdraw existing medication (Hoffman, Schiller, Greenblatte, & Iosifescu, ).…”

Potential Drug Interactions in Patients with a History of Cancer

“…With the changing demographics of an aging population, polypharmacy has become an increasingly pertinent issue in clinical practice [1][2][3][4][5][6] . In the literature, polypharmacy has been defined as the use of multiple drugs and of more drugs than clinically indicated.…”

“…In the literature, polypharmacy has been defined as the use of multiple drugs and of more drugs than clinically indicated. Despite the differences in definition, authors generally agree that the prevalence of polypharmacy has increased dramatically in recent decades and continues to increase [1][2][3][4][5][6] . Analyses of nationally representative surveys from the Swedish Panel Study of Living Conditions of the Oldest Old found that polypharmacy rates more than doubled to 46% in 2002 from 18% in 1992 6 .…”

The Ethics of Clinical Trials Research in Severe Mood Disorders

“…It should also be noted that psychiatrists have contended that there are sometimes indirect benefits to drug withdrawals that may be conferred on research participants 51 . Polypharmacy, the prescription of multiple drugs at the same time that usually entails adding drugs on top of other drugs that were only partially effective, is not well-studied.…”