Polypharmacy
There are a number of problems associated with polypharmacy in the ED:
Metabolism
MetabolismWhen an older patient is taking a lot of different medications, there are significant changes in metabolism as all those drug molecules compete for the few remaining hepatic molecules to metabolize them. Adding any new drug can upset that equilibrium. Remember the example of warfarin in the liver:
Warfarin binds with liver enzymes within liver cells.
When a new drug like TMP/SMZ, is added, it uses up some of the enzymes previously used to metabolize warfarin.
As a result, there are higher serum concentrations of BOTH drugs.
Important Note
As the case of Mr. Martini with his long list of medications illustrates, even a small medication change requires the liver to shift enzymes away from metabolizing other drugs. Thus more active drug is left available.
Communication
Polypharmacy also highlights the importance of good communication in the ED. If Mr. Martini had been told to expect a change in his INR he could have decreased or even stopped his warfarin. OR if his family doctor had been notified of the addition of the new medication, the family doctor could have started earlier monitoring of the INR. Older, perhaps cognitively impaired patients cannot be expected to “fill in” these blanks. It is the responsibility of the Emerg physician to ensure good communication.
Involving clinical pharmacists has shown to be helpful in the care of older patients with Polypharmacy or who are taking high-risk medications or presenting with adverse drug events (ADEs) in the ED. Communication is enhanced along with improved patient outcomes with inclusion of a pharmacy consult, if available.
Risks of Adding New Meds
When an older patient is taking a lot of different medications there is a risk of treating the adverse effect of one medication with yet another new medication.
Examples:
- Treating the itch caused by opioids with ©Benadryl;
- Treating the nausea caused by opioids with ©Gravol;
- Treating the gastritis caused by NSAIDs with an H1 blocker;
- Treating the cough caused by an ACE Inhibitor with codeine;
- Treating the nausea and urinary incontinence of cholinesterase inhibitors (for example ©Aricept) with anti-cholinergics (©Gravol and ©Detrol).
Unexpected Additive Effects
When an older patient is taking a lot of different medications there is a risk of unexpected additive effects: especially with anti-depressants, sedatives, or cholinesterase inhibitors the effect of adding even some ©Gravol or metoclopramide can be much stronger than on its own.
Unintentional Addition of Antagonist Drug
When an older patient is taking a lot of different medications, there is a risk of unintentionally adding an antagonist drug: for example, someone is on a cholinesterase inhibitor and then starting an anti-cholinergic; someone is on a beta-agonist (salbutamol) and then starting a beta-blocker; someone is on a dopamine agonist (LevoDopa) and then starting a dopamine antagonist (haloperidol).
Important Note
Polypharmacy or some kind of medication-related problem often presents atypically. To learn more about this issue, visit the Atypical Presentations module.
Discussion: Polypharmacy
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statins in palliative patients
benzos in elderly patients with depression not on antidepressants
Patients seen frequently on polypharmacy in my ED are those with End stage renal disease, ischemic heart disease, diabetes and hypertension.
Sometimes I have the feeling that all elderly patient have polypharmacy…
Prescribing cascades
coumadin with bactrim
pain meds with any other med
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i mentioned this in another response but almost every patient i see is on at least a dozen drugs. pcps in my system tend to just add and add and add rather than take the time to streamline med lists. they are so grossly overtaxed and under resourced that they just do not have the time to do what would be optimal care, so they just constantly add meds to put bandaids on complaints and then they stay on there forever. often patients are on lowest doses of multiple similar meds from different classes, even if they only have plain htn w no associated comorbidites that necessitate mutli-class regimen for one example
good attention
Common to see polypharmacy in anticoagulated patients
La principal polifarmacia es uso de anti hipertensivos y los analgésicos
Antihipertensivos tipos IECAS EN PACIENTES CON LESIÓN RENAL
HIPOGLICEMIANTES, anti-hta, tratamiento para el deterioro cognitivo, etc
multiple diuretics and anti hypertensive medications
drowsiness with morphine given for pain.
Warfarin side effects
ok
Patients who are bedbound, have dementia and are on 20+ medications, making it nearly impossible to determine what symptoms are real and what is being cuased by the medication. Also people coming in with syncope/presyncope following new antibiotics for UTIs.
Careful communication about changes to medication is important in all patients — but especially the older patient, potentially with some cognitive impairment, and multiple providers.
good
treating eps of haloperidol with Benadryl
patient with indwelling catheter but on flomax, dutasteride
Treating delirium with benzos and then giving haloperidol.
Analgesics
Anticholinergics and opioids for pain when not needed.
adding pain meds when not necessary
Multiple anti-hypertenstive, and anticholinergics and BPH meds presenting with hypotension
new medications started while on warfarin without review
while I don’t work in the er, i frequently see confused patient’s who are on a brand new prescription of morphine or fentanyl meanwhile they are having renal or hepatic insufficiencies.
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ok
Patient meds need to more frequently assessed to determine potential for Polypharmacy concerns
Nursing home patients coming to the hospital.
nearly every patient on at least 10 meds, often even more
a lady was confused after being started on hugh doses of lyrica, she was already on many drugs including an SSRI
…
ep
APIRIN,PLAVIX,CLEXANE AND OMEPRAZOLE
MORPHINE ABD GRAVOL
too many cooks in the kitchen- no communication between specialists and PCP of fully knowing the entire med list.
When you have patient come in with no GP so they see multiple doctors at walk in clinics and go to different pharmacies. They have had obvious prescribing cascades occurring.
Lots of renal toxic meds plus dehydration, PDEs, cardiac toxicity
use of tricyclic antidepressant, with an SSRI in old patients
so many…esp when pts getting rxs from more than one source. you have to be hypervigilente.
Taking anti cholinergics with Benz
Antihypertensive, glycemic control, Asa, drugs for dyslipidemia, all for one patient
Multiple medications for the same condition. Patients not sure why they take certain medicines because they have so many prescribed to them.
Percocet 10’s, muscle relaxer and gabapentin to elderly patient with bad kidneys
plavix ASA, beta-blockers, ACE, Duretics, Nitrates
it is so common to see a side effect treated with another drug
very informative
polypharmacy examples: patient with heart disease, hypertension, and diabetes.
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very fast
Some of the nursing home patients I have seen were on so many medications that they didnt have room for food!
it seems as though the medicines have medicines
OFTEN TIMES DON’T KNOW THE “NATURAL REMEDIES” PATIENTS ARE TAKING WHICH CAN CERTAINLY AFFECT THE RX MEDICATIONS IN ADDITION TO OTHER CONCERNS.
ok
hyperkalemia
elevated INR
sedation
great
GI disturbances very common in the elderly. Hypotensive and Hypoglycemia episodes secondary to drug use also very common in the elderly population in our region. Definitely, going to be paying more attention to the other drugs being used when I deal with elderly patients.
altered mental status, GI Bleed, chronic medication toxicity
Cognitive impairment leading to accidental multiple ingestions of Medications believed to not have been taken yet.
multiple meds
yes, and the fact that many docs of different fields do not talk to each other then the pt ends up on more meds than needed
Great information
Elderly patients on multiple medications with sedating side effects such as opioids and benzodiazepines, as well as being on blood thinners.
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good information
Had a case where a patient overdosed (more than prescribed dose) because she lost track as to which meds she had already taken for the day due to polypharmacy
excellent
Multiple medications, affects mental status
This is getting better. But still needs improvement. People still see too many doctors.
multiple meds in same family
Polypharmacy is a large problem. Many elderly are on over a dozen medications and they’re knowledge of the meds and compliance of them can often be questionable. These factors make it likely that problems will arise from this.
Polypharmacy frequently contributes to falls / delirium
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ok
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sda
MANY
yes
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multiple BP
k
Always watch that fluid intake
ok
review all medications
sometimes meds added without consideration to regular meds
ok
multiple meds in same family
too often we see another medication added in the ED without much thought of the full effects
A lot of polypharmacy and patients sometimes hospital shopping too so other medications are not reported accurately.
ok
Polypharmacy is a major problem. Most patients are on 15-20 medications, where they don’t know the name, dosage, or indication. It is difficult to prescribe new medications (unknown drug interactions) if the patient hasn’t ever been to the ED/ health system before and doesn’t know their home medications, which is very often.
X
Ask about all medications
less is more
ok
pain meds causing drowsiness
informative
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prednisone causing hypertension, leading to dizziness and loss of balance
Pts on 20 different medications, with acute delirium
attempts to relieve suffering can easily cause dangerous drug-drug interactions and involve Beers criteria medications
Bactrim with Zithromax
digoxin toxicity in renal failur
Some pts come in with long list and are not even understanding what they are for
Multiple blood pressure medications as well as pain medications.
multiple sedating medications causing altered mental status
pt on benzos for anxiety
Have seen a few patients come into the ER with gout who are on HCTZ and allopurinol
heart medications with blood thinners
Great example how to proceed with assessment and how to communicate to patient and their family
polypharmacy
n/a
lasix for pt with low BP
Es común la polifarmacia en los pacientes ancianos que buscan un medicamento a cada síntoma que presente,unas veces por prescripción facultativa y otra por automedicación
see this all the time, especially as the elderly have more and more comorbidities and see more and more specialists
During my clinical experience i have seen patients on more than five medication all schedule to be administered at the same time.
I’ve seen people on lists of 10 or more medications and its impossible to tell what is interacting with what at that point.
will have to ask
Can be difficult to control from the ED, clinical pharmacists are very helpful
Constipation is such a common problem with this population, and easily treated, however also usually a side effect of polypharmacy
multiple antihypertensive drugs
Patient education important get family involved.
Hctz
too many meds, extra meds to combat other meds, etc
htcz
anti-HTN meds on elderly pt who is “dizzy”
multiple medication especially with hypertensives and heart failure patients
diuretics
hctz
yes
anti-hypertensives, meclizine, warfarin and aspirin to start
a lot most multiple BP meds unnecessary
A lot with dehydration and lisinopril
Lots of supratherapeutic INR from warfarin DDI
ok
I often see new cardiac medications which cause presentations of syncope
medication management
examples of polypharmacy in the ED are based on the patients diagnoses
intersting
i don’t know i’ll have to investigate
long list of medications always in LTC
agreed
k
ASA and NSAIDS with bleeding
Polypharmacy also highlights the importance of good communication in the ED
examples of Polypharmacy I have seen is various drugs for the treatment of htn
Drug accumulation due to polypharmacology.
multiple drugs for depression/anxiety plus benzos in the elderly
many anti-hypertensives
polypharmacy
GI bleeds/NSAIDS, anti-hypertensives
Patients known for fibromyalgia for many years that have several pain killers (opioïdes, Lyrica, Elavil, etc.) and benzos for chronic fatigue (often long acting!). These meds were never re-evaluated when the patients got older.
Prescribing cascades are common and contribute to polypharmacy.
Plenty of cases of Polypharmacy. Most often seen is treatment of side effects of one medication with an other.
In my department patients always come in with a grocery bag full with meds. Or a container of some from. I guess the common one would be that most people are on a PPI like omeprazole or esomeprazole or pantoprazole. Whether it’s self medication or they are prescribed. And since this is a cytochrome inhibitor it can ultimately affect the metabolism of the host of drugs the patient is taking.
multiple antihypertensives
long list
Patient coming from nursing home have long list of medications ( Longest one was 32 medications)
pts on medications for primary prevention that are likely of no benefit given pt age/life expectancy… Pt in palliative care hospice on a statin…Important to reevaluate medication risk and benefit every now and then, especially when pts health takes turn for the worst
a variety
Significant bradycardia, hypotension, orthostasis, falls/fractures. Bleeding from high INR secondary to new medications. Significant AKI’s. Significant electrolyte disturbances.
warfarin and trimethoprim
multiple QT prolonging drugs.
or adding the sedative/laxative combination of snorlax to any medication
The most commonly encoutered example of polypharmacy I have encountered are geriatric patients prescribed PPIs despite having no Hx of GERD. This often leads to electrolyte imabalances or C. diff infections which could have been avoided.
Multiple antihypertensives
Benzos and opiods together
claritro with carba
Enalapril, hct, furosemide, insuline, medformine, epival
salbutamol inhalers for mild asthma then started on b blocker for ACS
on aspirin then started on clopidogrel for TIA then anticoagulant added.
Benzodiazepine with vicodin added for acute pain issue.
Hypotension
Confusion
Hyponatraemia
Hypovolaeia/dehydration
Drowsiness
Worsening kidney function
Digoxin toxicity
Raised INR
etc
This quite often happens in Parkinson patients. Without adequate recognition that they have Parkinsons I have seen patietns given maxolon and other antipsychotic medications without realising they are contraindicated.
old demented dm lady placed on tca for neuropathic presented with tca toxicity
Often patients come in on so many medications from a variety of physicians who are not coordinating that the only thing to do is to stop all the medications and then add back the ones that are really needed
I agree that sometimes this is necessary but who monitors this. I know when a patient gets admitted in the ED a pharmacist assess their drug record and tries to do a reconciliation. They should do that in the community pharmacies too. I recall a patient with A.fib given script to take Ventolin.
Do some drugs have a higher affinity for hepatic molecules than others? Meaning if two drugs are given concurrently could one with a higher affinity be metabolized quicker and the other with less affinity slower?
Often seen with older patients who have multiple comorbidities. It is pretty challenging, but a thorough medication hx is important to de-prescribe where necessary to prevent polypharmacy and its negative consequences.
multiple anti-hypertensives even after BP has stabilized
I always review the medication management plan of every elderly patient visiting OPD/ER
especially on polypharmacy and having cognitive impairment. I also discuss the medication plan with patient, caregiver and if possible send a copy to his/her family physician. I prepare the medication plan after discussing the activity of daily living with patient so that medications can be fit in according to activity of daily living.
being prescribed colchicine or allopurinol for gout after being prescribed HCTZ
patient with dementia started on memantine with tylenol cough had cerebral bleed and passed away
great
frequently treating side effects of one medication with another rather than addressing causes
ok
multiple sedative/ hypnotics- T3’s + clonzepam + amitriptyline
demented patient given benadryl for restlessness at night, already on a long list of meds for ischemic heart disease
An 85 yo with dementia on trazadone, mirtazapine, lorazepam, abilify among other medications he was taking.
great
Patient education and appropriate follow up
A new AFib patient started on warfarin & metoprolol by FD, with no instructions for f/u INR. Came to ED with a GI bleed and an INR of 18
we see it all
I have seen a patient with hemorrhage due to interaction between Septra and Warfarin. Hyponatremia due to unmonitored long term use of HCTZ.
A large percentage of older adults are presenting with polypharmacy.
giving stool softeners with stool firmers
I’ve seen a Tylenol overdose almost given Tylenol for pain
I have seen patients started on anti-cholinergic meds, NSAIDs when patients have a history of GI problems, and have seen patients started on opioids when already on benzos
Involving the pharmacist is valuable
Lack of communication in treating chronic disease between family Doc and specialists
different physicians prescribing different meds to same patient.
Mostly anti-depressant and cardiac drug polyOD
examples similar to what is listed
no ER
Poly-farm OD (intentional) seems to be a fairly common issue where I practice. There is depression/delirium rearing its ugly head again.
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d
could there not be a program in place to track and rectify these drug variables?
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prescribing one med to subtle the effects of another instead of investigating other options to replace the med
versed, morphine, gravol, NSAID
Common drug-drug interactions include adding beta blockers to patients who are on salbutamol; adding an anti-emetic for nausea in patients already on other anti-cholinergic drugs. Adding drugs which affect warfarin either through hepatic metabolism (Cimetidine) or compete for protein binding (ASA).
warfarin and omeprazole, warfarin and trimethoprim, terazosin and atenolol
i find less problems when I take the time to give all their meds a serious review before Rx’g anything new. I also consider what they may no longer require or could be weaned off and inform their FP
john’s wort and warfarin
interections with dig.
Dialysis patients are challenging cases.
patients unclear which medications they still take or do not take, multiple medications for multiple diseases
I have never seen a patient on warfarin who had the dose reduced when being prescribed antibiotics. I will definitely pay more attention.
Patients on warfarin and also on other drugs that affects the metabolism of warfarin.Pateints on clopidogrel and omeprazole concominantly.
polifarmacy its a big problem
multiple medications resulting in poor compliance or side effects
Patients taking two or more medicines out for one condition
Patients taking two or more drugs to a single condition
Mas de la mitad de los adultos mayores tienen polifarmacia
I believe more than 50% of elderly that com to the ED have polypharmacy issues.
Bisoprolol and ventolin
treatment of side effects with more meds, for example edema from taking amlodipine treated with diuretics.
I see people come in with a shopping bag full of medications from different MDs and even worse from different pharmacies. I have seen the same drug prescribed under different names so the pt. is being overmedicated.
that’s concerning and often seen
Yes, this is a concerning issue that I’ve encountered in our hospital as well. Although Netcare is supposed to help prevent this from happening, the development of a central database for monitoring is useful only if it’s actually monitored!
overdose on furosemide, treating ace inhibitor cough with codeine,
Medication review must beb part of all elderly visits/encounters
pharmacy follow through helps with continuity of care
incomplete follow through from md’s prescribing meds in er
discontinue certain meds?
multiple medications for different diseases
frequently the polypharmacy i see is when pts receive prescriptions from multiple HCPs who don’t communicate. The pts are unaware that some prescriptions overlap
We see polypharmacy all the time in the emergency department especially with elderly patients who live alone and do not have a blister pack.
Often we see patients who are having falls and low and behold are taking sedatives, anti-depressives and opiates. It’s important to assess their meds to see if they are contributing to their falls
We see polypharmacy all the time in the ER, it is difficult to eliminate drugs especially if you don’t know the patient well
Multiple drugs always carry a risk.
I have had so many patient show up with the shopping bag full of meds. It is important to go through them and see which are recent. People tend to keep old meds for some reason so to get an accurate list it is important to see which are old and new.
I have also seen the term “Prescribing Cascade” treating the side effect of one drug using another.
I’ve seen the “plastic bag of pills” sign so many times. Can we please have a public safety campaign about blister packs!!??!
One of the biggest problems I encounter is in the demented patient from the LTCF with an long list of medications that are not current, or medications are continued by the LTCF although the PCP thought they had discontinued them.
I think the most challenging patients are Dialysis patients. They are often on a list as long as your arm and some seem pretty tame ( like Tums) but they’re all important. Management of the meds and trying to reduce the number of times they take meds can help. Communication between ER and Dialysis becomes critical.
MD’s often only seem to add medications – it’s the easiest thing to do. This can end up with patient taking many medications which are then renewed time after time. Often it is better to reduce.
Great comment. And the Emerg Doc can play a role. “You might want to check with your mother’s family doc if all four of these BP pills are necessary?” OR “I’ll send a copy of the ED chart to your family doc suggesting she review medications that may lead to falls.” OR “I think the two different sleeping pills may be causing your falls. I’d suggest you stop one of them.” Too often we identify the problem but don’t go the next step in resolving it.
Good examples of how to speak to the patient/family and emphasize f/u.
I also find it helpful to ask the patient “Why do you think you fall/fell” as at times patients, who are best experts in their health/what their bodies are going through, will say, oh well I find that I get kind of dizzy after I take that pill etc and that can help with making links between meds and symptoms.