Polypharmacy—Time to Get Beyond Numbers

Steinman, Michael A.

doi:10.1001/jamainternmed.2015.8597

Cited by 54 publications

(43 citation statements)

References 8 publications

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“…GPs may not want to alter medications started by a specialist) [43]. Multidisciplinary interventions are generally observed to be the most effective at reducing polypharmacy and inappropriate medication use [78,79], and the involvement of pharmacists and nurses in a deprescribing process appears to be a path to enhancing deprescribing in practice [80]. Many patients are comfortable with the involvement of a pharmacist or nurse in the deprescribing process (with GP involvement) [51,54].…”

Section: Opportunities For Deprescribing: Working With Patients and Omentioning

confidence: 99%

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Reeve

Thompson

Farrell

2017

European Journal of Internal Medicine

223

202

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Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.

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Section: Opportunities For Deprescribing: Working With Patients and Omentioning

confidence: 99%

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Reeve

Thompson

Farrell

2017

European Journal of Internal Medicine

223

202

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“…Proton pump inhibitor (PPI) drugs are associated with complications, such as Clostridioides difficile infections or kidney toxicity, and older adults are particularly vulnerable to such adverse events . Moreover, PPIs contribute to polypharmacy, prescription drug costs, and aging‐related complications (eg, osteoporotic fractures) …”

mentioning

confidence: 99%

“…[1][2][3][4][5][6] Moreover, PPIs contribute to polypharmacy, prescription drug costs, and aging-related complications (eg, osteoporotic fractures). 7,8 Despite these harms, many PPI prescriptions are potentially low value, meaning they lack an evidenced-based indication. 9,10 Promisingly, six randomized PPI deintensification trials in a metaanalysis found that deprescribing can reduce PPI use and pill burden.…”

mentioning

confidence: 99%

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

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“…This study suggests that there is limited value to defining polypharmacy with strict cut-offs for identifying risks without regard for drug type (Gnjidic et al, 2012; Laflamme, Monárrez-Espino, Johnell, Elling, & Möller, 2015; Steinman, 2016). Conventional definitions of polypharmacy, such as five or more medications, have been validated largely in elderly populations (Gnjidic et al, 2012).…”

Section: Discussionmentioning

confidence: 97%

Polypharmacy and risk of non-fatal overdose for patients with HIV infection and substance dependence

Kim

Walley

Heeren

et al. 2017

Journal of Substance Abuse Treatment

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Introduction People living with HIV (PLWH) are at risk of both polypharmacy and unintentional overdose yet there are few data on whether polypharmacy increases risk of overdose. The study objective was to determine if the number and type of medication (e.g., sedating) were associated with non-fatal overdose (OD) among PLWH with past-year substance dependence or a lifetime history of injection drug use. Materials and Methods This was a longitudinal study of adults recruited from two urban, safety-net HIV clinics. Outcomes were i) lifetime and ii) past-year non-fatal OD assessed at baseline and a 12-month follow-up. We used logistic regression to examine the association between each outcome and the number of medications (identified from the electronic medical record) in the following categories: i) overall medications, ii) non-antiretroviral (non-ARV), iii) sedating, iv) non-sedating, as well as any vs. no opioid medication and any vs. no non-opioid sedating medication. Covariates included demographics, medical comorbidities, depressive and anxiety symptoms, and substance use. Results Among 250 participants, 80% were prescribed a sedating medication, 50% were prescribed an opioid; 51% exceeded risky drinking limits. In the past month, 23% reported illiict opioid use and 9% illicit opioid sedative use; 37% reported lifetime non-fatal OD and 7% past-year non-fatal OD. The median number (interquartile range) of total medications was 10 (7, 14) and 2 (1, 3) sedating. The odds of lifetime non-fatal OD were significantly higher with each additional sedating medication (OR 1.26, 95% CI 1.08, 1.46) and any opioid medication (OR 2.31; 95% CI 1.37, 3.90), but not with each overall, non-ARV, or non-sedating medication. The odds of past year non-fatal OD were greater with each additional sedating medication (OR 1.18; 95% CI 1.00, 1.39, p=0.049), each additional non-ARV medication (OR 1.07; 95% CI 1.00, 1.15, p=0.048), and non-significantly for any opioid medication (OR 2.23; 95% CI 0.93, 5.35). Conclusions In this sample of PLWH with substance dependence and/or injection drug use, number of sedating medications and any opioid were associated with non-fatal overdose; sedating medications were prescribed to the majority of patients. Polypharmacy among PLWH and substance dependence warrants further research to determine whether reducing sedating medications, including opioids, lowers overdose risk.

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Polypharmacy—Time to Get Beyond Numbers

Cited by 54 publications

References 8 publications

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Polypharmacy and risk of non-fatal overdose for patients with HIV infection and substance dependence

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