By Jennifer Devinney, RPh, PharmD Polypharmacy is an often silent, but very serious, problem in PACE pharmacy today. It is defined as the administration of more medication than is clinically indicated, which represents unnecessary medication use. Thorough PACE medication management is key to limiting polypharmacy. Polypharmacy is especially prevalent in elder care where it has been estimated that approximately a quarter of patients are prescribed nine or more medications, with some studies showing much higher percentages of patients exceeding five, nine or ten medications.
Defining NecessityFor a medication to be considered necessary, it should be prescribed with a clear diagnosis that is supported by practice guidelines, clinical research or standards of care at a dose, duration, frequency and route of administration in concurrence with these guidelines. Additionally, medications should be used at the lowest effective dose for the shortest duration possible, avoiding duplication of therapy with other agents. The medication should be monitored according to practice guidelines, including periodic lab levels as well as clinical monitoring for therapeutic response and the development of adverse effects. When prescribing a medication, definitive therapeutic goals should be established in addition to the indication for use. Having clear therapeutic goals is vital in order to appropriately assess whether a medication is beneficial as therapy progresses. It also enables the healthcare team to create a larger and more comprehensive care plan for the participant. [Tweet “With seniors taking multiple medications, #polypharmacy is a growing concern in #PACEpharmacy”]
The Role of Medication ReviewA thorough medication review when a participant is accepted is one of the most important PACE pharmacy practices to help eliminate unnecessary medications. It’s important to determine why a participant is using a particular medication and to match each medication to an appropriate diagnosis. Often, medications are associated with a general diagnosis, no diagnosis or a diagnosis that is not an FDA-approved indication. In these cases, clinical judgment should be utilized to determine whether the off-label use is appropriately supported based upon the participant’s medical history and if the benefits of therapy outweigh the risks of adverse effects. The psychotropic medication class, which includes antipsychotics, anxiolytics and sedative/hypnotics, is one of the highest risk medication classes for the geriatric population. The risk of adverse events, including increased mortality, is very high in the elderly—making the risk versus benefit line with psychotropic medications extremely tenuous. When psychotropic medications are used outside of their FDA-approved indications, the literature supporting their use is lacking. In fact, most literature does not recommend off-label use due to lack of positive outcomes. Due to inherent risks, psychoactive medications need to have a clear goal of therapy, which includes specific target behaviors that support the use of the medication. Adverse effect monitoring is extremely important for this class since these medications carry substantial risks, and periodic dose reductions are necessary to provide evidence that the lowest effective dose is being utilized. Optimizing medication regimens when more than one agent is being used to treat a condition is another important practice for preventing polypharmacy. The most prevalent example of this would be using multiple agents to manage hypertension. It’s not uncommon to see as many as four or five antihypertensive medications ordered for the same participant. One of the fundamental guidelines in treating a disease state that may require more than one medication is to start with one medication and maximize the dose until either the maximum recommended dose is reached or the maximum dose without adverse effects is reached. After the maximum dose is reached, then another agent can be added and titrated if better control is needed. participants on multiple medications at suboptimal doses should have their regimen evaluated and, if clinically acceptable, have a medication discontinued while adjusting the doses of the other medications.
Drug Classes of Particular ConcernProton pump inhibitors (PPIs) are one of the most commonly prescribed unnecessary medications. PPIs are frequently utilized for treatment of GERD in the elderly. Practice guidelines recommend treating GERD initially with PPIs for eight to 12 weeks and then evaluating whether the GERD has improved. Often, the evaluation does not occur and many participants will remain on PPIs for years without any dose reductions to see if the dose or medication is still needed. Long term use of PPIs increases the risk of certain complications, such as osteoporosis and clostridium difficile infection. Allergy medications prescribed for long term chronic use are another commonly seen unnecessary medication. Many times allergy symptoms such as runny nose and itchy eyes are often seasonal or otherwise short-lived, yet the participant is ordered a long term scheduled dose of an antihistamine medication. It’s important to periodically evaluate whether these medications are still necessary since they have adverse effects such as drowsiness. Trial, as-needed orders are a good way to check whether this type of medication is still necessary. Some other more commonly seen unnecessary medications include:
- Overactive bladder medications for participants who are already incontinent
- Antihyperlipidemic medications for participants with hospice-qualifying disease states such as advanced stages of COPD, congestive heart failure or renal failure
- Scheduled cough and cold medicines used beyond an acute illness
- Some vitamins and supplements