Physicians discuss managing prescriptions for patients with chronic, comorbid conditions
As Americans take more prescription drugs and over-the-counter medications, physicians increasingly are having to cope with issues related to polypharmacy-arguably one of the most vexing prescribing issues they confront on a daily basis.
Polypharmacy, which is the practice of taking multiple medications--typically four or more-to manage a patient’s diseases and health conditions has become an increasingly alarming issue in medicine.
“Polypharmacy is driven by a combination of factors, including people living longer, the increasing prevalence of chronic diseases such as diabetes and the increasing availability of drugs to treat many of these diseases,” says internist Caleb Alexander, MD, codirector of the Johns Hopkins Center for Drug Safety and Effectiveness in Baltimore, Maryland.
Data from the National Center for Health Statistics (NCHS) show that older patients use the greatest number of prescription drugs. According to a 2015 NCHS report, from 2009 to 2012 3% of adults between the ages of 18 and 44 took five or more prescription drugs during the prior month, compared to 16% of those aged 45 to 64. Among people age 65 and over nearly 40% took five or more drugs.
Another area of concern is the use of pain relief medications. A 2013 NCHS report indicates that among people either taking pills to relieve pain or those that have developed a dependence on this class of drugs, use of prescription opioid analgesics increased 300% between 1999 and 2010. Death rates for poisonings involving opioid analgesics more than tripled between 2000 and 2010.
Physicians’ efforts to better manage polypharmacy are hampered by fragmentation of care, the lack of interoperability among electronic health record (EHR) systems, and challenges that arise as patients take supplements and other tablets that complicate their course of treatment.
The battle to cope with polypharmacy at many medical practices is overwhelming, doctors say. NCHS data back up these claims, indicating that 2.3 billion prescription and over-the-counter drugs were recorded in physician office visits in 2012.
Managing polypharmacy, and ensuring that every medication a patient takes is appropriate and is not having harmful interactions with other drugs is part of a physician’s responsibility, says Nitin Damle, MD, FACP, president of the American College of Physicians. He adds that there are several steps doctors can take to keep track of their patient’s medications, including:
Making sure that practice staff follow up on any medication-relation issues. For example, when calling to remind patients of their next appointment, ask them to bring all their medications with them. This is especially important for patients on multiple medications who recently visited an emergency department, were hospitalized or spent time in a rehabilitation center.
Primary care physicians should ask patients to let them know if a specialist prescribes them any additional medication(s).
Continuously review medication regimens and confirm that there is an indication, no drug interaction and no side effects.
Trying to keep patients on the lowest dose possible and question them closely about new symptoms.
Ensuring that the patient is deriving therapeutic benefit from all drugs he or she is taking and that their benefits outweigh any side effects.
Ensuring any side effects the patient experiences are tolerable.
Damle, who is part of an eight-physician internal medicine practice in Wakefield, Rhode Island, says his practice has been a patient-centered medical home (PCMH) for eight years. The PCMH model uses a team-based approach to addressing polypharmacy issues.
Under this approach, Damle explains, his practice shares a pharmacist with other practices. The pharmacist is on-site two days a week and available at other times for consultations. The practice also has a clinical nurse care manager to collaborate on care, which includes reviewing medications and corresponding diagnoses as part of every visit.
“Each time a patient comes into the office a team that consists of a patient intake medical assistant or nurse, a diabetic nurse and a clinician evaluates his or her list of medications to assess whether they are appropriate and whether some can be stopped,” Damle explains. The patient consultations are also used for clarifying what medications the patient is taking.
Reviewing drug interactions is part of educating patients. This is especially important when patients have been discharged from hospital, in which case dosage updates, any changes made at discharge or any further adjustments are made during the office visit, Damle says.
Still, while care coordination has improved, Damle says that gaps remain. One example is the inability of pharmacies to note medications that have been discontinued and do not need refills. In addition, he notes, EHRs’ lack interoperability makes it difficult to track medication changes from other treating physicians.
While physicians are implementing measures to curtail the effects of polypharmacy, a confluence of events make polypharmacy an ever-increasing threat to patients and the healthcare system, says Alexander.
Explaining how easily patients can slide into polypharmacy, Alexander cites the example of a patient with asthma, osteoporosis, depression and coronary artery disease. Such a patient could quickly end up taking 10 medications.
In such a case it’s easy to imagine that the patient would use a steroid inhaler for prevention, a rescue inhaler on an as-needed basis and montelukast for asthma.
In addition, the patient might also be taking calcium, vitamin D and bisphosphonates for osteoporosis, a selective serotonin reuptake inhibitor for depression, and aspirin, a statin and an ace inhibitor for the coronary artery disease.
“We do live in an over-medicated society and there’s no question that there are tens of millions of people that are taking medicines that they don’t need,” Alexander says.
As healthcare providers and administrators continue to look for ways to hold down costs while keeping patients healthy, ensuring that patients take medications that don’t result in adverse drug events is critical. Not only can a patient’s illness worsen from drug interactions, but dangerous drug interactions can lead to costly hospital admissions and readmissions.
Gerald DeVaughn, MD, a cardiologist with a solo practice in Philadelphia, treats a patient population in which 80% are on five medications or more. He notes that at least 70% of his patients suffer from three or more chronic illnesses, including coronary diseases, hypertension, diabetes and kidney disease.
DeVaughn says he evaluates patients’ medication lists during every visit. For those patients who know their medications well a verbal check-off will do.
For others, he requests that they bring their medicine bottles with them. That enables DeVaughn to reconcile his medication list with what the patient is actually taking, and confirm patient adherence by checking dispense dates. He also attempts to reduce the number of medications the patient is taking.
“I try to minimize drugs use and there are many occasions when I’ve made patients better by reducing the number of medications they are taking,” DeVaughn says.
A recent study by the American Heart Association highlighting the dangers of polypharmacy to heart failure patients, suggests that doctors like DeVaughn will have a lot more work to do to tackle the problem. The AHA data show that heart failure patients take an average of 6.8 prescription medications per day, in addition to over-the-counter, complementary and alternative medications.
Medicare beneficiaries experiencing heart failure see 15 to 23 different providers each year, according to the study. Researchers say that could contribute to the number of medications prescribed to them. The risk of heart failure is exacerbated by direct myocardial toxicity, drug interactions or both, resulting in a greater likelihood of patients being admitted to the hospital.
The study also found that heart failure is the leading discharge diagnosis among patients 65 and older, and that the estimated cost for treating heart failure in Medicare recipients-now $31 billion-is expected to increase to $53 billion in 2030.
DeVaughn says he’s acutely aware that his patients receive care from numerous doctors, all of whom operate independently and often don’t share information in a way that can best address a patient’s medication issues.
The fragmentation of care is made worse, DeVaughn says, by the fact that his EHR doesn’t interact with the EHRs of other doctors his patients see. Thus, when medications are changed by other doctors, or if DeVaughn wants to start a new medication, that information is not immediately transmitted to all the patient’s physicians.
He adds that if he changes a medication, he’ll send letters to the primary care physician and copies to the other specialists treating the patient.
Yet another factor complicating polypharmacy management is patients’ increasing use of supplements, such as herbs and vitamins. In an article published last year in JAMA Internal Medicine researchers, including Alexander, used a longitudinal national survey of people age 62 to 85 to further investigate older people’s pill-taking habits. The study compared data from 2005 to 2006 with 2010 to 2011.
The researchers found that more than a third of older adults take at least five prescription medications and almost two-thirds use dietary supplements, while 38% take over-the-counter medications.
The study found that in 2011 approximately 15% of older adults were at risk for a major drug interaction, compared to 8% of older adults who were at risk six years earlier.
Alexander advises doctors to be vigilant and look for opportunities to de-prescribe. He also suggests that doctors always consider over-the-counter drugs and supplements as part of the patient’s medication regimen, particularly for patients who are prone to taking a large number of medications because of their comorbidities or those with cognitive impairment.
“There’s no magic bullet here, this is a problem that’s as perennial as the grass, but the more physicians are aware of the problem the better able they will be to address it,” Alexander says.
Keith Davis, MD, owns and operates a solo primary care practice in Shoshone, Idaho, where he treats approximately 400 patients with combinations of chronic illnesses, such as diabetes, congestive heart failure and hypertension. Most of these patients, which account for 8% of his patient panel, take five or more medications, he says.
Davis’s biggest challenge is determining whether polypharmacy is appropriate. That’s because there are instances when patients will need more than five medications, such as a patient that has congestive heart failure and diabetes.
Once those classes of medications are chosen he must try to find specific ones that don’t interact in ways that harm the patient.
“The actual number of medications itself isn’t necessarily bad,” Davis says. He adds that doctors need to know if the medications patients use are treating their conditions, and multiple medications may be required for successful treatment or management of a condition.
Davis adds that there have been times when a specialist changed a patient’s medication, but the change wasn’t communicated to his office.
“All of a sudden we have a patient with new symptoms and new problems and sometimes that’s because they’re taking a new medication that was prescribed that we were not aware of. Unfortunately sometimes those patients ended up in the emergency room before we had a chance to work with them,” Davis says.
To deliver better care and lessen the risks associated with polypharmacy, Damle says, primary care physicians can play a critical role by making sure they are treating patients appropriately and with the correct medications, and reviewing drug interactions and discussing patient adherence
during every visit.
“If we can get polypharmacy issues under control we’ll be able to keep patients healthier and potentially keep them out of the emergency room or out of the hospital,” Damle says. “It also means we can reduce the overall cost to the healthcare system.”