by Dr. Derelie (Dee) Mangin
The scenario is familiar: you or your mother or father has multiple pills to take at multiple times of the day. A pillbox called a dosette may be used to try and reduce the confusion and keep things on track. Where’s the problem? Surely if you need the pills to stay healthy, then you need the pills?
The problem is the more pills you take the more likely you are to have a side effect and that your pills are going to interact with each other or with one of your conditions. So a pill that looks like a good idea on the face of it, when added to the cocktail of your other pills and illnesses can give you more problems than it solves.
If you’re taking more than five pills you’re twice as likely to have a side effect than if you’re taking fewer than two.
Prescribing cascades can be triggered too. This is when a drug causes symptoms that are a side effect that is not recognised as a side effect leading to treatment with another drug that causes its own side effect that is treated with another drug… and so the cascade continues, like a series of dominoes, until you fall over in the end – sometimes literally.
Your mother might be given an anti-inflammatory drug, develop high blood pressure, be given a diuretic to treat this, develop gout….. If she had her blood pressure measured after a trial of stopping the anti-inflammatory drug the cascade may never have got started.
When the number of pills leads to confusion, it’s often impossible to take them all – which could be protective but in the chaos the pills that get skipped might also be the ones that are really needed.
The average number of drugs most older adults are taking in developed countries is around 7.
When you consider that if you have one chronic illness you are likely to have multiple this is not surprising. The majority of people attending primary care now have multiple chronic conditions. About half of people over 65 have at least three coexisting chronic conditions. One in five has five or more. But while things get worse as we age, most people with multiple conditions are under 65 .
Clinical trials exclude these very patients – they almost never include people with multiple illnesses of taking multiple drugs. So we are in the middle of an enormous global experiment with almost no data collection. Its time we got to grips with this – looking beyond diagnoses and back to patients.
What do you do with an invisible elephant in the room?
More people die of adverse drug effects in Europe alone each year than die of colon cancer, or breast cancer, or prostate cancer. It’s the equivalent of more than a jumbo jet or two every day. If this was an airline, would you fly on it?
Yet this cause of death and illness is largely lost in the hype around the need to treat diabetes or hypertension or osteoporosis. There are no measures in place to prevent death from this far more common cause of death.
What causes this wave of dangerous caring?
Modern medicine treats diseases not patients. Quality of care has morphed into ‘following the guidelines’. But these guidelines are for diseases not people. If you’re a doctor and a guideline adherer, then quality of care measures will rate you highly.
But applying guidelines in a 75 year old with 5 chronic conditions, no matter what they are, results in risky polypharmacy. This is illustrated wonderfully in a study that showed that applying the guidelines for an average number of chronic conditions in an older patient resulted in 19 doses of 12 different medications taken at 5 different times of day with 10 possibilities for drug-drug or drug-disease interactions.
Extrapolating the data from partial statistical lives in clinical trials doesn’t work in the complex lives of real patients.
So valuing quality of care on the basis of treatment for diseases rather than care for patients makes harmful polypharmacy invisible.
The doctors who provide care that is measurably better in terms of guideline adherence provide care that is meaningfully worse for the patient.
But the patient centred doctor who listens to the patients priorities and tries to minimise the potential for the harms of polypharmacy would be rated as poorer doctor on measures of care that are tied to adherence to disease based guidelines and targets.
Doctors more and more feel the pressure not to discontinue medications in order to remain congruent with ‘best practice’. This is made worse when faced with health policy pronouncements that variation in practice is bad and standardization is the answer to improved health outcomes. It can drive doctors to initiate or continue prescription, where they otherwise wouldn’t. It has over-focused the medical system on efficacy and on initiating and continuing treatments.
There are some patients who do need many medications. But being realistic, most people taking long term medicines are not benefiting from them.
For half of people taking a medicine to be benefit, the ‘Number Needed To Treat’ would be 2 – that is for every 2 people that take a medicine, 1 benefits. The Number Needed to Treat for most drugs used for chronic disease is well into double digits. This means that most are exposed to the risks without hope of benefits.
Even these estimates of benefit are optimistically skewed by commercial and publication bias towards positive results. Until we have access to patient level data for independent analysis, the work of the Cochrane Tamiflu group and Peter Gøtzsche’s Nordic Cochrane Group show we can’t really know how great these benefits are likely to be, nor the extent of the potential harmful effects.
Drugs are frequently being taken by patients on the basis of data on surrogate outcome measures, which are just numbers and rating scales, rather than things that really matter to patients. When things that matter to patients are finally measured, on average the treatment effect estimate was nearly twice as high in the trials using surrogate outcomes than in the trials using final patient relevant outcomes.
Using preventive treatments in older age can simply shift the causes of illness and death without making life longer or better. We are like cars – if the clutch, the alternator and the piston are all failing, putting in a shiny new clutch won’t make the car go better or last longer.
Doses in the older age group is often higher than needed because of reduced body mass, and because starting doses from trials are often too high even for younger adults.
Things that are risk factors at a younger age don’t play out the same way in older age, and sometimes the relationship even reverses. For example blood pressure – older people need a slightly higher blood pressure, and applying the guidelines for younger people can be dangerous.
But maybe because we are sensitive about ageism, we think it a good thing to start medicines for the elderly also and we are nervous about stopping, when, given the data, the reverse should be true.
As medicine becomes increasingly specialized and subspecialized fragmented prescribing means fragmented responsibility – the more prescribers you have the more likely you are to have an adverse effect from your medicines.
Most people on more than five drugs have never had a review of their medication. Why is this?
The whole framework of medical care is centred around the therapeutic imperative to ‘do things’. There is really no less-is-more framework to not doing things or stopping things.
We desperately need a new kind of preventative medicine – Quaternary Prevention, which is the process of preventing the harms of excess medical care. Without a review and trial of discontinuation there is often no way to know whether a drug is still needed – if blood pressure is normal the assumption is that it’s the pills that are keeping it that way – but blood pressure medications can often be withdrawn in older patients without the need for restarting.
This is not just a matter of taking a pill for nothing. Pills for blood pressure lead to a higher rate of falls resulting in serious injury such as hip fracture and head injury.
When prescribing gets fragmented, you are the Patient may be the person best placed to help start the conversation about deprescribing. You can set the doctors mind at rest about ageism. You are the person best placed to ensure you get what-matters-to-you medical care rather than treatment for diseases.
Trials of multiple medication discontinuation ‘deprescribing’ show that this can be done successfully and that it leads to lower death rates and less hospital admissions.
Deprescribing is the process of working out whether you would be better off on less medicines, or a lower dose of some of your medicines. It needs an ongoing conversation with your doctor pharmacist of nurse practitioner around what matters most to you and what the risk benefit balance looks like for you or each of your drugs.
Deprescribing might mean having a controlled ‘pause’ in one or more of your medications, carefully monitoring what happens and then using this information to decide whether ‘less is more’ in this case. Think of it as a drug holiday. It might mean lowering a dose and observing what happens rather than stopping.
Teamwork is important because there are some drugs you shouldn’t stop suddenly and there are others where successful discontinuation is more likely if you taper the drug slowly – this includes diuretics, blood pressure medications, antipsychotics, proton pump inhibitors and others.
At RxISK we are interested in trying to find solutions – helping support the teamwork between doctor and patient around polypharmacy, and helping you work out whether you might be on too many drugs or could benefit from a lower dose of some of your drugs. We’ve used a parrot as the logo – parrots are chatty birds, they hang around where cocktails are served and they’re also intelligent. We’ve tried to create something that will help start the conversation and in doing so overcome some of the barriers to addressing polypharmacy.
A RxISK Polypharmacy Index. To calculate your RxISK PI click here by checking on some of the things that increase the risk of you taking a drug cocktail that’s of more harm than benefit to you. This will give you a RxISK Polypharmacy Index. The higher the number, the more you need to start the conversation with your doctor and / or pharmacist. You can print out the responses to the questions and your score to take with you and form the basis for intelligent conversation with your doctor, pharmacist or nurse practitioner.
Click here to use our Interaction Checker on this site to see if there are any possible interactions between your drugs and illnesses. You’ll have to log in the first time to use this as we have to pay a small fee on your behalf any time someone uses the service.
(If you find it useful and want to make a donation to help support this that would be great too!)
Dr. Derelie (Dee) Mangin
David Braley and Nancy Gordon Chair in Family Medicine
Dr. Mangin’s research focuses on contributing significantly to the body of scholarship on family medicine; developing, implementing and evaluating curricular innovations; undertaking quality research dedicated to evaluating the critical role of the family physician; and developing improved models of family medicine and primary care service.
The chair is being supported by a donation from David Braley, president of Hamilton-based Orlick Industries Limited, and his wife Nancy Gordon, a registered nurse who trained and practiced in Hamilton hospitals.