The evolution of polypharmacy: appropriate and problematic polypharmacy, choosing the right strategy and tactics

Abstract

The evolution of polypharmacy, which for many years consisted of quantifying concurrently prescribed drugs, has led to an qualitative description: “appropriate polypharmacy”, which may be beneficial for some patients, and “problematic polypharmacy”, which is harmful. The concept of “appropriate polypharmacy” is to prescribe multiple drugs based on the best evidence, taking into account the patient’s clinical condition and potential drug-drug interactions. With age, the prevalence of geriatric syndromes, comorbidity/multimorbidity, and limitation of life expectancy increase, which reduces the positive benefit/risk ratio for most drugs. The problem with polypharmacy is associated with an increased risk of adverse reactions, drug-drug interactions, and decreased patient compliance. To improve polypharmacy, various methodologies are used to optimize drug use for maximum benefit and least harm. Such interventions include professional patient counseling, the use of additional tools (including Bierce’s criteria, STOPP/START, MAI index, etc.), electronic decision-making systems, educational programs. The effectiveness of interventions to reduce polypharmacy has been evaluated in several Cochrane meta-analyzes (2012, 2014, 2018) and showed a decrease in drug misuse and the risk of ADR, but there was no effect on mortality, and few studies found a decrease in the number of hospitalizations. The deprescribing methodology is especially relevant in the context of problematic polypharmacy and is considered an integral component of the continuum of good prescribing practice, promoted as a strategy to reduce polypharmacy and improve patient outcomes. Among other interventions, deprescribing has the most evidence for its utility in preventing drugrelated complications, improving clinical outcomes, and reducing costs. The International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP) in 2018 developed 10 recommendations to reduce polypharmacy and potentially inappropriate drugs. Thus, the concept of “appropriate polypharmacy” is a rational approach to optimizing polypharmacy; it should be promoted to replace existing thresholds.