Polypharmacy: Dangers for Americans young and old.

Polypharmacy, the taking of too many medications, is a growing problem in the United States and some other industrialized countries.  However, Americans are by far more overmedicated than other nations utilizing almost 95% of the world prescriptive medications produced. This problem affects the elderly especially. 

In fact, a full 35.8% of older adult Americans take five or more medications at a time, and approximately 15.1% of them are at risk for a potential major drug-drug interaction, according to results of a longitudinal, nationally representative study published in JAMA Intern Med. in 2016.  

To circumvent potential problems in patients taking multiple medications, clinicians must carefully evaluate which are appropriate and which may not be.  For many doctors it is very easy to start a patient on a medication, but often taking them off is wrought with fear that the patient may falter.

As a consequence, medication list expands and rarely shrink and this continues for the lifetime of the patient.  This is especially true for elderly patients, who are not only more likely to be taking several different medications but are also more likely to suffer detrimental effects of each drug and the drug-drug interactions that result.

Experts at the American Geriatrics Society are currently in the process of reviewing a 2018 update of the Beers Criteria, the latest version of which was published in 2015. 

The 2018 Beers Criteria will be updated to include information on the harms and benefits of particular medications in the elderly, possible interactions with other drugs, and drugs to avoid.  Clinicians use the Beers Criteria as a guide when prescribing meds.

Also, the advent of Pharmacogenomics and understanding how gene expression and the metabolism and competition for P450 metabolism pathways can also be used to help curtail drug-drug interactions.

Here is a look at some common medications that have been shown to have deleterious effects:

 

Statins (like Crestor and Lipitor) for primary prevention:  Currently, no evidence exists to prove the benefits of statins for the primary prevention of cardiovascular events in patients over 75 years old. However, there is a push by some to get more and more folks on this long-term medication.  Thus, researchers recently conducted a large, retrospective study published in the British Medical Journal.  It studied 46,864 patients aged 75 years or older (followed for 5.6 years) without clinically diagnosed atherosclerotic cardiovascular disease to assess the effects of statin treatment on cardiovascular mortality. They found that in those older than 74 years who did not have type 2 diabetes, statin treatment did not reduce the incidence of atherosclerotic cardiovascular disease or all-cause mortality.

Proton-pump inhibitors (PPIs/ Prilosec, Nexium): In a BMJ study published 2017, researchers from the US Department of Veterans Affairs found that mortality risks may be high in PPI (Prilosec and Nexium are examples) users compared with non-users, in those without gastrointestinal conditions, and in those using PPIs for prolonged periods of time. Use of PPIs should be avoided long-term in the elderly. Short term use seems to be OK, until the root cause of the dyspepsia (usually GERD) is resolved.  Not only do they increase the risk of Clostridium difficile infection, but up the risk of bone loss and fractures as well.  C. diff infections can cause a very bad type of diarrhea that may even become fatal.  Bone loss due to PPI use will worsen or start the process of osteoporosis and result in larger numbers of fractures after falls.

Benzodiazepines (Valium and Ativan) and Z-drugs: In the elderly, chronic use of benzodiazepines and the Z-drugs [zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta)] should be avoided. The list of reasons includes increased sensitivity and decreased metabolism and excretion of these agents that occur in older patients, as well as the increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes and possibly increased risk of dementia (Alzheimers).  Finnish researchers of a 2018 study published in Acta Psychiatrica Scandinavica found that benzodiazepine use, was associated with a modest increase risk of Alzheimer’s disease.  Longer use and higher dose made matters worse.

Aspirin: For the primary prevention of cardiovascular disease and colorectal cancer, aspirin should be used with caution in those aged 70-years and older.  In a large study published in late 2018 in the New England Journal of Medicine, researchers followed 19,114 patients and concluded that low-dose aspirin used in older persons as primary prevention carried a significantly higher risk of major hemorrhage (GI and brain bleeds) and did not significantly lower the risk of cardiovascular disease.  For those at high risk of stroke or heart attacks it may be beneficial, but low risk individuals the risks outweighed the benefits. A call for more individualization of therapy, not just cookie-cutter the recommendations.

NSAIDS: Although NSAIDs (both prescription and OTC such as Ibuprofen, Celebrex, Mobic) are commonly prescribed, they are one of the most common causes of adverse drug reactions in the elderly.  Researchers of a recent review published in Aging and Disease in 2018 concluded that elderly patients are very susceptible to the side effects of NSAIDs.  When prescribing NSAIDs, clinicians should be cognizant of the increased risk for falls, psychiatric events, GI-bleeds, bruising, and stroke, and carefully weigh the risk/benefit ratio to optimize outcomes.

There are many protocols to reduce the use or burden of too many medications (Polypharmacy) and a skilled practitioner should know and utilize the process.  Some can be stopped immediately; others require a longer tapering-off period. The process is very often very individual for each patient based on co-morbid factors, age, and number of medications involved. 

The providers at Carolina Holistic Medicine are well versed in medication reduction and safer alternatives if warranted. 

References:  

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2500064

https://www.bmj.com/content/362/bmj.k3359

https://bmjopen.bmj.com/content/7/6/e015735

https://onlinelibrary.wiley.com/doi/epdf/10.1111/acps.12909

https://www.nejm.org/doi/full/10.1056/NEJMoa1805819

http://www.aginganddisease.org/EN/10.14336/AD.2017.0306

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