How Many Pills Are Too Many?
By Austin Frakt
THE NEW HEALTH CARE APRIL 10, 2017
The point of prescription drugs is to help us get or feel
well. Yet so many Americans take multiple medications that doctors are being
encouraged to pause before prescribing and think about “deprescribing” as well.
The idea of dropping unnecessary medications started
cropping up in the medical literature a decade ago. In recent years, evidence
has mounted about the dangers of taking multiple, perhaps unnecessary,
medications.
Deprescribing will work only if patients also get involved
in the process. Only they can report adverse effects that they sense but that
are not apparent to clinicians. And they need to be comfortable weaning from or
dropping drugs that they are accustomed to and believe to be helpful.
Yet an increasing number of Americans — typically older ones
with multiple chronic conditions — are taking drugs and supplements they don’t
need, or so many of them that those substances are interacting with one another
in harmful ways. Studies show that some patients can improve their health with
fewer drugs.
Though many prescription drugs are highly valuable, taking
them can also be dangerous, particularly taking a lot of them at once. The vast
majority of higher-quality studies summarized in a systematic review on
polypharmacy — the taking of multiple medications — found an association with a
bad health event, like a fall, hospitalization or death.
About one-third of adverse events in hospitalizations
include a drug-related harm, leading to longer hospital stays and greater
expense. The Institute of Medicine estimated that there are 400,000 preventable
adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of
patients discharged from the hospital have a drug-related complication after
returning home, many of which are preventable.
Not every adverse drug event means a patient has been
prescribed an unnecessary and harmful drug. But older patients are at greater
risk because they tend to have more chronic conditions and take a multiplicity
of medications for them. Two-thirds of Medicare beneficiaries have two or more
chronic conditions, and almost half take five or more medications. Over a year,
almost 20 percent take 10 or more drugs or supplements.
Some are unnecessary. At least one in five older patients
are on an inappropriate medication — one that they can do without or that can
be switched to a different, safer drug. One study found that 44 percent of
frail, older patients were prescribed at least one drug unnecessarily. A study
of over 200,000 older veterans with diabetes found that over half were
candidates for dropping a blood pressure or blood sugar control medication.
Some studies cite even higher numbers — 60 percent of older Americans may be on
a drug they don’t need.
Though studies have found a correlation between the number
of drugs a patient takes and the risk of an adverse event, the problem may not
be the number of drugs, but the wrong ones. Some medications have been
identified as more likely to contribute to adverse events, particularly for
older patients.
For example, if you’re taking psychotropic agents, such as
benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and
cognitive impairment. Diuretics and antihypertensives have also been identified
as potentially problematic. (The Agency for Healthcare Research and Quality has
published a longer list of drugs that are potentially inappropriate for older
patients. Note that, even if they are problematic for some patients, they are
appropriate for many.)
Relative to the mountain of evidence on the effects of
taking prescription drugs, there are very few clinical trials on the effects of
not taking them.
Among them is one randomized trial that found that careful
evaluation and weekly management of medications taken by older patients reduced
unnecessary or inappropriate drug use. Adverse drug reactions fell by 35
percent. Medication use was reduced, along with the risk of falls among a group
of older, community-dwelling patients through a program that included a review
of medications.
Several other studies also found that withdrawal of
psychotropic medications reduced falls. A comprehensive review of deprescribing
studies found that some approaches to it can reduce the risk of death. Another
recent randomized trial found that frail and older people could drop an average
of two drugs from a 10-drug regimen with no adverse effects.
So why isn’t deprescribing more widely considered? According
to a systematic review of research on the question, some physicians are not
aware that they’re prescribing inappropriately. Other doctors may have
difficulty identifying which drugs are inappropriate, in part because of lack
of evidence. In other cases, doctors believe that adverse effects of drug
interactions are outweighed by benefits.
Physicians also report that some patients resist changing
medications, fearing that alternatives — including lifestyle changes — will not
be as effective. Other studies found that many doctors are concerned about
liability if something should go wrong or worry they’ll fail to meet
performance benchmarks — like the proportion of diabetic patients with adequate
blood sugar control.
To reduce the chances of problems with medications, experts
advocate that physicians more routinely review the medication regimens of their
patients, particularly those with many prescriptions. At hospital discharge —
when patients leave the hospital, often on more medications than when they
entered it — is a particularly important time for such a review. Including
nurses and pharmacists in the process can reduce the burden on physicians and
the risks to patients.
Patients can play an important role as well. Walid Gellad, a
physician in the Veterans Health Administration and at the University of
Pittsburgh School of Medicine, advises that at every visit with a doctor,
“patients should ask, ‘Are there any medications that I am on that I don’t need
anymore, or that I could try going without?’ ”
Patients, of course, should not try weaning themselves off
medication without consulting their doctors — but deprescribing is an idea for
all parties to keep in mind.
Reprinted from: https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0
