There is often a lot of debate around what we mean by polypharmacy and, in particular, deprescribing. This is how we describe these two synergistic areas:
Polypharmacy is now recognised as two distinct types:
Appropriate Polypharmacy which is beneficial to a patient, e.g. the combination of medicines prescribed following a myocardial infarction. This requires ongoing assessment of the patient’s response to treatment to ensure all prescribed medicines remain appropriate and safe.
Potentially Inappropriate Polypharmacy which, for the individual, has become problematic as the harm outweighs the benefits and therefore the patient is taking more medicines than are clinically needed and no-one is really managing them, this is often due to multiple prescribers. Inappropriate polypharmacy is NOT just about taking multiple medications, it also occurs where a medicine no longer aligns with the goals of care, is an ineffective or unnecessary treatment, or has become high risk, particularly in patients with increasing frailty.
There is a need to promote a more 'Mindful Prescribing' attitude in all medication review opportunities and highlights that even one or two medicines may reflect inappropriate prescribing for some patients. This may also include the need to optimise medicines to ensure appropriate polypharmacy, e.g. beta blockers in heart failure titrated to correct dose.
A Prescribing (or prescription) Cascade occurs when a new medicine is added to treat a side effect of another previously prescribed medicine, this is often misdiagnosed as a new problem and can result in both appropriate and inappropriate polypharmacy. It may lead to yet another iatrogenic problem and the cascade continues. A cascade can be reversed through deprescribing.
Deprescribing is synergistic with inappropriate polypharmacy and is the process of tapering, withdrawing, discontinuing or stopping medicines to reduce potentially problematic polypharmacy, adverse drug effects and inappropriate or ineffective medicine use by regularly re-evaluating the ongoing reasons for, and effectiveness of medication therapy. This should be done in partnership with the patient (and sometimes their carer) and supervised by a healthcare professional, it can be effective in reducing medication (pill) burden in patients to improve their quality of life while still maintaining control of chronic conditions.
Deprescribing must be done judiciously, with monitoring, to avoid worsening of disease or causing withdrawal effects. This needs careful discussion on an individual basis to gain patient understanding and acceptance. It may be helpful to use different terminology for patients. Treatment and care should take into account individual needs and preferences. People who use health and social care services should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals and social care practitioners. It is recognised this is a complex process, not a single act, involving multiple steps.
Gnjidic D, Le Couteur DG, et al. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing & clinical outcomes. Clin Geriatr Med 2012; 28: 237–253.
Reeve, E., Gnjidic, D., Long, J., and Hilmer, S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. British Journal of Clinical Pharmacology. 2015. 80(6), 1254-1268.