'Bag of Pills': Is It Necessary?

WASHINGTON -- Polypharmacy is a difficult problem for many physicians who treat older patients, but there are steps they can take to cut down on their patients' medications, Amit Shah, MD, said here at the American College of Physicians annual meeting.

"I do a lot of medical student and resident teaching, and whenever I teach this topic, I like to say, 'As a geriatrician, I have cured more disease by stopping medications than starting them,'" said Shah, who is at the Mayo Clinic in Scottsdale, Ariz. "It's a bit of an overstatement but it gets people's attention" because they never thought about fixing problems by taking medications away rather than adding things on."

Shah added that he is not a "nihilist," and that he likes the fact that physicians have drugs they can offer patients. In addition, he noted that "Underprescribing can be just as much a problem as overprescribing."

However, there are reasons why some patients get prescribed more drugs than they may actually need, Shah said. One is "prescribing inertia" -- the patient is already taking the drug, so when it comes up for a refill, the doctor automatically refills it. Electronic medical records make it amazingly easy to approve a refill, he added.

As an attending physician, "I once almost killed [an 86-year-old] patient who didn't get killed by their saddle pulmonary embolism (PE) ... he had been on four blood pressure medicines prior to admission," Shah said. At discharge from the intensive care unit, the intern just hit "continue" on the computer four times, and kept all four of the medications going, even though "[the patient's] heart was not the same heart it was prior to his PE ... he goes to the coumadin clinic and his blood pressure was 60 systolic; he was a little woozy! His saddle PE didn't kill him but me and my intern almost did."

"If the intern had to write out four new prescriptions like we did once upon a time, he wouldn't have started the patient on four new blood pressure medications at discharge ... This was a systems issue," Shah said.

Other reasons polypharmacy occur include the assumption that there must be a thoughtful provider behind each prescription, "not wanting to step on the toes" of the original prescribing provider, and patients and providers not wanting to "rock the boat."

Shah listed his 10 steps for successful medication "debridement":

• Find out all of the medications the patient is taking. The best way to do this is with a home visit, according to Shah. "Make sure you think about things like over-the-counter (OTC) medications." He cited one study showing that 70% of hospital discharge records had at least one medication reconciliation error when compared with the medications actually taken at home; 30% of these errors were potentially serious.
• Assess whether each medication is potentially harmful. There are many drugs for which safer alternatives exist -- for example, patients could be prescribed glipizide rather than a long-acting sulfonylurea such as glyburide or glimepiride. There are also several lists of medications -- such as the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults and the Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) that physicians may want to consult, Shah said. However, he cautioned that these are not "blacklists" and physicians who do need to prescribe these medications should be wary of insurers trying not to cover them because they are on the list.
• Consider whether the drug is actually approved for the indication you're prescribing it for. Shah noted that about 20% of all prescribing is off-label; for psychiatric drugs, it's about 40%.
• Think about whether the drug has outlived its usefulness for that patient. He compared the way some drugs "attach" themselves to patients with the way Arizona's jumping cholla plant attaches itself to people. Shah said he asked one patient why he was taking omeprazole. The patient's response: "It's for my heart, doc. [I went in for] chest pain, and they gave this to me, and I haven't had a twinge of chest pain ever since." Shah then asked the patient if he had ever had heartburn. He said no "and then he told me his recipe for five-alarm chili and proceeded to tell me all the spicy foods he can eat ... In the ICU, a lot of patients end up on PPIs [proton pump inhibitors] and they just continue it," whether it's necessary or not.
• Consider whether a drug's side effects outweigh its benefits. Shah gave the example of Aricept (donepezil) for dementia and noted that although the results of the clinical trials of the drug were highly statistically significant, the average increase in score on the ADAS cognitive scale for patients on the drug was only 3 points out of 70. The drug does work occasionally for hallucinations and for patients with Lewy body dementia, and that it helps with word-finding difficulties in a few patients. "These medications have a role, but not as much as we think," Shah said. He noted that the package insert itself says Aricept doesn't affect the course of the disease, but, 20% of patients taking the drugs had side effects, including bradycardia and increased risk of new-onset urinary incontinence. Also, the brand-name drug costs about $300 per month.
• Watch out for drug-drug and drug-disease interactions. "I'm not smart enough to [figure out] all the drug-drug interactions when a patient is on 20 different medications," said Shah. But an electronic reference such as Epocrates can suggest some drug-drug interactions that may be important to look at. "Electronic medical records are [also] good at this, but we get alert fatigue," he added.
• Look for reactions with any herbal medications or other OTC drugs. For example, calcium supplements decrease absorption of levothyroxine, quinolone antibiotics, and tetracyclines, and "these are clinically significant," he said. Time of administration can also be a factor: One of Shah's patients didn't have a problem with her TSH level until she moved to an assisted living facility at which she was given all her drugs at one time, rather than spacing out her levothyroxine and her calcium supplement, as she had been doing at home.
• See if the drug you're prescribing is being used to treat the side effects of another drug. This problem is known as the "prescribing cascade" -- a drug that is prescribed has a side effect, so the physician puts the patient on a second drug to deal with the side effects of the first one, and so on. Shah said he was able to "cure" Parkinson's disease-like symptoms in a patient with diabetes who began having Parkinsonian-like symptoms after she was put on metoclopramide (Reglan), which had been prescribed for nausea and vomiting. That patient had been put on levodopa by her neurologist, but her symptoms mostly disappeared once the metoclopramide was stopped, Shah said.
• Look for a nonpharmacologic approach to try instead of a drug. For example, he said, patients with urinary incontinence can be prescribed scheduled voiding and Kegel exercises. Patients with sleep problems can be counseled about normal changes that occur with sleep during the aging process, and be advised to consider relaxation techniques and napping. Addressing the underlying issues can help -- for instance, if a patient is having sleep problems due to pain, prescribe acetaminophen before bedtime rather than Ambien (zolpidem) for sleep.
• Think about whether the patient will live long enough to gain a benefit from the drug. Shah gave the example of a 102-year-old patient who was put on a statin for primary prevention after her physician discovered she had hypercholesterolemia. The ePrognosis app can help with this issue by estimating the prognosis for elderly patients, he said.

Being successful in decreasing polypharmacy can be very satisfying, he noted. "It's really fun when you unwind six to seven medications in your patients, which I've done, and they feel better."