Embracing the Right Polypharmacy in Older Adults With HF

Patrice Wendling

October 14, 2020

About half of older adults hospitalized with heart failure (HF) take at least 10 medications and that proportion is increasing over time, according to a new study.

"I felt this was an opportunity to really outline how prevalent this issue is and also hopefully to inspire discourse about how exactly to optimize outcomes in a population where polypharmacy is common," senior author Parag Goyal, MD, MSc, Weill Cornell Medicine, New York City, told theheart.org | Medscape Cardiology.

Most clinicians who care for older patients with HF know they take a lot of medications, but detailed real-world information is limited, he said. Another factor behind the study is the recent boom in HF medications, such as sacubitril-valsartan and the sodium-glucose co-transporter-2 (SGLT2) inhibitors.

"I sort of describe it as the gold age of heart failure," Goyal said. "There are up to 10 different medications now that have been demonstrated to provide benefit, particularly in heart failure with reduced ejection fraction. As a heart failure doctor, it's amazing; I can actually offer treatment to these patients. But the issue of polypharmacy does need to be considered; otherwise, we're at risk of prescribing, prescribing, prescribing, and possibly causing harm."

A high medication burden can increase the risk for adverse drug events, lower medication adherence, and negatively impact quality of life. Older patients are especially vulnerable because they contend not only with their HF, but also with age-related conditions, such as multiple comorbidities, frailty, and cognitive impairment, he said.

For the study, Goyal and colleagues focused on 558 adults at least 65 years of age with an adjudicated HF hospitalization at 380 different American hospitals between 2003 and 2014 in the prospective observational REasons for Geographic and Racial Differences in Stroke (REGARDS) study. The median age was 76 years, 44% of the participants were female, 34% were Black, and the median number of comorbidities was five.

Polypharmacy is broadly defined in the general population as taking at least five medications daily, but results showed that almost everyone in the cohort was doing so at either admission (84%) or discharge (95%). As such, polypharmacy was defined as at least 10 medications and was present in 42% of patients at admission and 55% at discharge.

"A cutoff of 10 medications to identify polypharmacy may be optimal for identifying older adults with heart failure at greatest risk for harms related to high medication burden," the researchers write in the study, which was published online October 13 in Circulation: Heart Failure.

Over time, the prevalence of polypharmacy increased at hospital admission from 25% in 2003 to 2006 to 55% in 2011 to 2014 (P for trend < .0001) and increased at discharge from 41% to 68%, respectively (P for trend < .0001).

Patients with polypharmacy had a higher median comorbidity count and higher prevalence of functional impairment upon admission than those without polypharmacy. A similar pattern was found for both HF with preserved or reduced ejection fraction (HFpEF/HFrEF).

Noncardiovascular medications made up the majority of medications taken at both admission (median, 50%) and at discharge (median, 46.7%). Proton pump inhibitors and multivitamins were two of the most common of these medications, but the value of starting or continuing either is debatable, Goyal and colleagues suggest.

Electrolyte supplements were also among the most used noncardiovascular medications. Use of mineralcorticoid antagonists, however, was low in the cohort, despite being part of guideline-directed medical therapy for HF, but could provide an alternative strategy to combat hypokalemia, they noted.

The top three most common HF drugs were beta-blockers, loop diuretics, and angiotensin-converting-enzyme (ACE) inhibitors, whereas aspirin, statins, and calcium-channel blockers were the three most common non-HF cardiovascular drugs.

"Let's embrace the fact that there are all these drugs that can help patients, but let's just make sure that we're reviewing all their medications on a regular basis to be sure that each of those individual meds is indeed the right med for that particular patient at that time of their disease," Goyal said.

Commenting on the findings, cardiologist Scott Hummel, MD, University of Michigan, Ann Arbor, said it's not surprising that patients are on more medications than they used to be, given that the number of comorbid conditions in HF patients has been rising over the past 10 to 20 years, as have the metrics for quality of care and guideline-based therapies.

However, "the balance point is something that we haven't put a lot of effort into thinking about yet and it's going to be different for every patient," he said. "So it's not as simple as this answer is good for the whole population, the whole cohort."

In a related editorial, Hummel noted that the study did not account for regimen complexity but that mortality-reducing therapy in HFrEF can now involve up to six medications dosed up to three times a day. At the same time, the number of comorbid conditions was the only independent predictor of polypharmacy in the study, which explains why it was equally common in HFpEF.

"The heart failure with preserved ejection fraction is a really interesting group because there isn't evidence-based therapy for that group and yet they're on as many or more medications," he told theheart.org | Medscape Cardiology. "So there may be more of an opportunity to make these deep dives, if you will, on the individual patient situation in that group."

Part of a deep dive should also involve assessing goals of care and patient preferences, said Rachel Denny, DO, who coauthored the editorial and is a geriatrician at the University of Michigan.

"It's about taking that step back and asking, 'what is your goal as the patient and what do you want?' And that's a tough one to assess when you have limited time in the clinic and you're trying to cover everything with the patient," she said in an interview.

Nevertheless, geriatric screening instruments, such as the Mini-Cog test, PHQ-2, Mini Nutritional Assessment short form, and Clinical Frailty Scale, can be administered quickly with little training and can provide crucial prognostic information and guide multidisciplinary consultation.

Goyal agreed a multidisciplinary approach is needed to address polypharmacy and that there's a lot to achieve during an office visit with an older HF patient with multiple comorbidities.

"We need to develop strategies that can encourage our clinicians to take the time to spend with patients with regard to their medications," he said. "Does that mean we need reimbursement strategies that reimburse for time spent reviewing medications, reviewing adverse drug reactions, conducting medication reconciliation? Maybe."

The National Institute of Neurological Disorders and Stroke and the National Institute on Aging of the National Institutes of Health (NIA) funded the study. Goyal is supported by a grant from the NIA and from the American Heart Association. Denny and Hummel reported having no conflicts of interest.

Circ Heart Fail. Published online October 13, 2020. Abstract, Editorial

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