What Is Polypharmacy?

No drug is completely risk free

Polypharmacy simply means too many prescription drugs. It is a legitimate diagnosis, and it is itself a disease state—one that physicians should more frequently assess and more frequently try to help their patients avoid.

While appropriately used pharmaceutical agents are beneficial and often life saving, NONE are completely risk free. The very first fact one learns on the first day of medical school (and one of the most important concepts in all of medicine) is this: "Any medicine can cause any side effect, at any time"—even months after its discontinuation.

Drug side effects are extremely common, regardless of a drug's safety profile. Adverse effects include true allergic reactions, hypersensitivities, and poorly tolerated new symptoms, even when a drug does work properly.

Side effects are not only cumulative, as one drug is added to another, but also multiplicative, and occasionally, even exponential. For example, a three-drug regimen, compared to a two-drug regimen, might increase the chances of a bad side effect between two and 27-fold in any given individual.

Imagine, then, what a four- or five-drug regimen might do. Or a 10- to 20-drug regimen. Yes, some physicians actually maintain patients on this number of drugs, and some patients, remarkably, take them. (My personal all-timer was a patient who initially came to me on a regimen of 35 drugs. He loved them all. In my opinion, he needed perhaps four of them.)

And, all this does not even take into account the over-the-counter (OTC) drugs that a patient may take, about which his or her physician may or may not know.

Good medical practice and good patient outcomes are NOT proportional to the number of drug prescriptions a physician writes for any given patient. In fact, the opposite is usually true—prescription parsimony is usually better than prescription profligacy.

There should be a clear indication for any given drug. Will it really benefit the patient? There should be constant reassessment of its need. It is perfectly fine to take away a drug if there is no need for it or if the chances of a side effect far outweigh potential benefit. (In other words, if the "therapeutic index" is low, for that drug, in that patient, at that time.)

You should expect from your physician(s) this constant reassessment of your medication regimen. A medications review should be part of every medical visit. If it is not, the best medical practice will not likely occur. (You should help your physician by bringing to EVERY visit either all of your medication bottles or a completely accurate written list of all the medications you take, both prescribed and OTC.)

Nevertheless, for some conditions, medical science DOES recommend that multiple drugs ARE necessary, even with the increased risk of side effects and high costs. Some examples are diabetes, heart failure, kidney failure, AIDS, and severe psychiatric illnesses. For these conditions, four-, five-, and six-drug regimens are common and do constitute good medical practice. For the extremely common disease of hypertension, at least two drugs are almost always necessary (and sometimes three or four).

Patients frequently have several conditions at the same time, especially diabetes, heart failure, kidney failure, and hypertension. Fortunately, some common drugs used for these conditions overlap in their indications, so that many good drugs treat two, three, or even four conditions at the same time. Obviously, use of such drugs, whenever feasible, diminishes polypharmacy.

In general, it is always advantageous to use one drug that might simultaneously improve two or more conditions that a patient might have, as both costs and risks of side effects are reduced. For example, some drugs are efficacious for both depression and pain, heart failure and hypertension, angina and hypertension, migraine headache prevention and seizures, diabetes and infertility, and acne and birth control. These are just a few examples from a very large list. There is a single class of drugs, for example, that is theoretically efficacious in simultaneously treating depression, anxiety, insomnia, chronic pain, and bladder dysfunction—and perhaps even helps with migraine headache prevention and smoking cessation—all for four dollars per month. Wow!

It is always appropriate to ask your physician these questions:

• What is this drug for?
• Do I really need it?
• Do I need so many drugs?
• Can we eliminate some, especially the expensive ones?

We physicians would do well to ask ourselves these same questions every time we pull out the prescription pads or pound the electronic medical record's computer keypad.

So, for me, based upon my training, experience, and ongoing medical research, when it comes to drugs, "less is more" (therapeutic drug nihilism, if you will) and is still a good attitude.

Until sooner,   

Eli Goodman, MD
Medical Insights Blog