Interventions to reduce polypharmacy, or the ongoing use of multiple medications daily, appear to reduce potentially inappropriate prescribing and improve medication adherence significantly, according to a new review.
At the same time, the effects of these interventions on clinical and intermediate outcomes were inconsistent, and the overall certainty of evidence was low.
"We would love to see a system of routine care that takes a look at and prevents the harms of polypharmacy," senior study author Dee Mangin, DPH, the David Braley Nancy Gordon Chair in Family Medicine at McMaster University in Hamilton, Ontario, told Medscape Medical News.
"We need to recognize the importance of conversation and listening to patients' priorities and preferences," she said. "We have to stop looking at patients as collections of diseases and drugs and instead consider what's in the best interest of the patient."
The study was published online July 13 in Canadian Family Physician.
Inconsistent Intermediate Effects
The long-term use of multiple medications has been associated with an increased risk of adverse health outcomes, drug reactions, and long-term negative effects on physical and cognitive functioning, the study authors write. The risk of adverse health outcomes such as falls and hospitalization is estimated to be 13% with two medications, 58% with five medications, and 82% with seven or more medications.
In Canada, about 27% of older adults report taking five or more medications daily. Polypharmacy interventions, which have been developed in recent years to reduce the number or dosage of inappropriate medications, could help lower the risk of potential negative effects.
To summarize the existing evidence, the investigators conducted a review of systematic reviews on the effects of polypharmacy interventions for older adults living with multiple conditions. Among 21,329 text citations, they reviewed 619 full texts. They included five systematic reviews published between 2014 and 2019 in their analysis.
Among the five reviews, the mean number of medications taken daily ranged from 5.7 to 9.4. The sample sizes in the reviews ranged from 1925 to 61,006. Three studies were rated as being of low quality, one was of moderate quality, and one was of high quality.
In all five reviews, the polypharmacy interventions produced statistically significant reductions in potentially inappropriate prescribing and improved medication adherence. Two reviews found that the interventions also reduced healthcare resource usage and expenditures.
The research team found that the observed effects were inconsistent for intermediate outcomes, such as blood pressure and glucose control, as well as clinical outcomes, such as all-cause mortality.
None of the five reviews reported any significant benefits of polytherapy interventions for quality-of-life outcomes. In addition, the reviews reported no significant differences in adverse drug events outcomes.
"We Weren't Surprised"
The overall quality and the certainty of evidence in the reviews were reported as low to very low. This could be attributed to the complex nature of polypharmacy interventions, as well as a mix of study designs, settings, sample sizes, and outcome measurements, the study authors write.
"We weren't surprised by this because we know the literature, but we want to understand why," Mangin said. "Why doesn't something that appears to be a good idea benefit patients?"
Mangin and colleagues are developing a theoretical model to determine the reasons why polypharmacy interventions may or may not work, she said, as well as a new strategy that focuses on patient priorities, such as mobility, cognition, and social interaction.
The idea is to involve patients, doctors, and pharmacists in ongoing conversations about medications. Patients have expressed interest in an occasional "drug holiday," Mangin said. These allow for tapering of doses and monitoring patients regularly for side effects and important quality-of-life outcomes such as cognition.
"The proper pathway is to start up front with priorities that are most important to patients and the functional benefits," she said. "What are the drugs they would stop if they could? What mix would be most effective? What are the cumulative side effects?"
Older adults, in particular, could benefit from these conversations, she said, as the numbers of health conditions and medications increase with age.
"Each condition — taken in isolation — is associated with medication recommendations. The result is a large number of medications for some seniors," Michelle Greiver, MD, the Gordon F. Cheesbrough Research Chair in Family and Community Medicine at North York General Hospital in Toronto, told Medscape Medical News.
Greiver, who wasn't involved with this study, is leading a randomized controlled trial of polypharmacy interventions across five provinces. Called the Structured Process Informed by Data, Evidence, and Research (SPIDER), the study brings together patients, family physicians, other healthcare professionals, and quality improvement coaches to discuss patient health and prescriptions.
"Seniors value independence, and prevention in the community is important," she said. "Last but not least, the patients have said this is important to them and their families. Will it work? We don't know — that is the reason for a randomized controlled trial."
The review was supported by funding from the Labarge Center for Mobility in Aging at the McMaster Institute for Research on Aging and the Canadian Institutes of Health Research. Mangin and Greiver have disclosed no relevant financial relationships.
Can Fam Physician. Published online July 13, 2022. Full text
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Cite this: How Do Polypharmacy Interventions Benefit Patients? - Medscape - Jul 22, 2022.