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Too many pills on the kitchen table

Section Editor(s): Bushardt, Reamer L. PharmD, PA-C, DFAAPA

Journal of the American Academy of PAs: April 2018 - Volume 31 - Issue 4 - p 8–9
doi: 10.1097/01.JAA.0000531057.20126.1e
Editorial
Free

Reamer L. Bushardt is professor and senior associate dean at the George Washington University School of Medicine and Health Sciences in Washington, D.C., a clinical, translational scientist in the Children's National Health System in Washington, D.C., and editor-in-chief of JAAPA.

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During my pharmacy training, I spent some of my most memorable clinical training experiences in a family medicine residency program in the Pee Dee area of South Carolina. My pharmacist preceptor, and subsequently long-term mentor, Kelly Jones, PharmD, BCPS, was gracious with his time and expertise and created numerous opportunities for me at “the front of the line” to hone my drug therapy skills and optimize teamwork with physicians. Kelly opened my eyes to the epidemic of inappropriate polypharmacy; thanks to his inspiration, I have spent the last 20 years studying drug injury and helping older adults try to maximize the benefits and avoid unnecessary risks from complex medication regimens.

A few months after training with Kelly, I was rotating in a Veterans Administration Medical Center (VAMC) with a team of pharmacists who managed patients in a chronic care clinic after their diagnoses were established by one of the unit's internists. These pharmacists focused on medication management for chronic illnesses such as diabetes, cardiovascular disease, asthma, and COPD. I will never forget the first patient, a 75-year-old retired VA nurse with a past medical history that went on for days and a whopping 45 daily medications. Without a doubt, this patient, like many older adults, was living with polypharmacy, or as Kelly used to say, “too many pills on the kitchen table.” My preceptor seemed overwhelmed, but I was ready with an approach developed in that rural family medicine residency program—a simple, reliable approach that I continue to use today.

So, next time you enter the clinic room and see a table full of little “soldiers” lined up ready to greet you (this is what I call the visual of a lot of amber prescription bottles wearing those little white hats that accompanies a patient with polypharmacy), I hope you might consider these nine questions. This model for screening for inappropriate polypharmacy, which I first shared with JAAPA readers in the May 2005 issue (https://journals.lww.com/jaapa/Fulltext/2005/05000/Nine_key_questions_to_address_polypharmacy_in_the.5.aspx), remains my favorite and most practical strategy to combat unnecessary medications.

  1. Is each medication necessary? We now have considerable evidence of the low clinical utility of many drugs that were commonly prescribed in the past. PAs can minimize polypharmacy by prescribing only medications that have demonstrated their usefulness for a particular condition. Prescribing medications that are not indicated or that have a paucity of clinical evidence often brings more harm than benefit. Verify that each drug prescribed is indicated and that the patient has an active diagnosis for which the drug has been shown effective. A pocket drug reference or smartphone app such as Micromedex can provide answers in seconds.
  2. Is the drug contraindicated in older adults? If you are treating a frail or older patient, check if any current medications are contraindicated. Most pocket drug references offer guidance on safety in older adults, or tools like the Beer's criteria have handy tables to assess potential risk quickly. Keep in mind there are no absolutes, so use the information and your own assessment of the patient to inform treatment discussions.
  3. Are there duplicate medications? As older adults require more healthcare, especially from providers across multiple medical and surgical specialties, this question is increasingly important. When care changes hands, such as right after a hospital discharge, is another prime time for duplicate drugs. Check to see if any medications are duplicated or if concurrently prescribed medications convey similar pharmacologic effects, such as anticholinergic effects, sedation, or psychomotor agitation.
  4. Is the patient taking the lowest effective dosage? For older adults, the old adages “start low, go slow” and “less is more” often are true. Because the pharmacokinetics and pharmacodynamics of many drugs are altered by normal physiologic changes of aging, instead of asking what a drug may do to an older patient, a PA can ask what effects aging may have on a particular drug in a specific patient. The most common example I encounter is improper drug dosing based on renal function. A quick look at a drug reference (and some 7th-grade math if the reference does not offer a drug dosing adjustment table) is all it takes to fix that issue. A lower but equally effective dosage of a medication also may save the patient some money.
  5. Is the medication intended to treat an adverse reaction to another medication? Scan for the drug cascade, or a drug prescribed to treat adverse reactions to a previous drug, and so on. When a drug is added to treat an adverse reaction to another drug, a PA must evaluate the risk-benefit ratio of the initial drug, the discomfort for the patient, the added cost of adjunct therapy, and consider any existing medications that may serve as safer, equal, or more effective alternatives to the initial drug. Common precipitants of the cascade for older adults include antidepressants, NSAIDs and other analgesics, and cold or allergy medications.
  6. Can I simplify a drug regimen? Life is complicated enough for many older adults without us convoluting their medication regimens. If your warfarin prescription says take one tablet on Monday, Wednesday, and Friday; half a tablet on Tuesday and Thursday; skip Saturday; and just lick a tablet on Sunday, you should try again. Complicated and multidose daily regimens lead to errors, so strive to keep it simple.
  7. Are there potential drug interactions? The app I mentioned early, Micromedex, has a nifty tool to screen and qualify drug-drug and drug-food interactions and can offer quick answers. Remember to ask patients about consumption of alcohol, grapefruit juice, and over-the-counter (OTC) products that might not already be in their medical record.
  8. Is the patient adherent? Continuing to prescribe medication for a patient who is not taking it appropriately is another form of polypharmacy. Inquire without judgment, so you can get to the bottom of the cause of nonadherence. Studies demonstrate that a careful explanation of the purpose of a drug increases adherence rates.
  9. Is the patient taking an OTC medication, an herbal product, or another person's medication? Gathering an accurate and comprehensive drug history from patients is no easy task. Verify the drug history yourself; do not assume that what was compiled in the initial workup is accurate. Polypharmacy has an uncanny effect to exaggerate amnesia when it comes to getting an accurate history.

If I am evaluating a particular patient complaint, I use all nine questions to evaluate related medications. If I am seeing a new patient and want to quickly screen for potential inappropriate polypharmacy, I rapidly ask the questions in sequence about each of their medications. If I get a concerning answer to a question, I stop there, denote the medication as potentially inappropriate, and move on to the next drug. Usually, you can take time to make reductions or eliminations; in fact, often it is better not to make too many changes at once. But, next time you see that lineup of “soldiers” and an older patient who does not appear in optimal health, do not panic. All you have to do is ask the right nine questions.

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