Polypharmacy is a snowballing issue that goes with the increases in medical knowledge and improved life expectancy. Medicines are keeping us alive for longer, but as we live longer we have more medical problems for which we need medicines.
What is polypharmacy?
Polypharmacy is the use of multiple medications at the same time by one person. In other words, it means being on lots of different medicines. Usually a person who is on quite a few different pills has more than one medical condition.
There is no single definition of polypharmacy. It isn't defined as being over a specific number of medicines.
Polypharmacy is becoming a common problem. This is partly because of the ageing population. People are living longer, so they are more likely to have more than one long-term medical condition which needs continual treatment. With improving medical knowledge and treatments, people survive events such as a stroke or heart attacks which, 30 years ago, would have often caused them to die. Instead of this, it is now commonplace to emerge from hospital after a heart attack in fine form but on six different pills to stop it happening again. Also research has shown that a number of medicines can be used to prevent illness. Increasing numbers of guidelines recommend treating people at risk of certain medical conditions. Guidelines in the UK for the use of the cholesterol-reducing medicines called statins, for example, recommend their use in pretty much everybody over the age of 70 as well as many under the age of 70, even if their cholesterol levels are normal. This is because statins have been shown to reduce your chances of having a stroke or a heart attack.
People who are likely to be affected by polypharmacy are older people, and those with more than one long-term medical condition.
Why does it matter?
All medicines have pros and cons. That is, benefits and possible harms. Harms include side-effects, risks and bad reactions. When you take any medicine - even something like an over-the-counter painkiller for a headache - you should weigh up the risks against the benefits. Doctors only prescribe medicines if it is more likely that the benefits will be greater than the possible risks. However, medicines affect different people differently, so it isn't always possible to predict that a medicine will cause a problem. Even the most common side-effects of any one pill only affect a few people. So the more medicines you are on, the more likely it is that at least one of them will cause either a side-effect, or some kind of long-term damage. If you get to the point where you feel so unwell from the side-effects of your medicines that life is not enjoyable, it may no longer be worth taking so many to prolong your life. It might be better to have a better quality of life than a longer one. Prescribing is all a balancing act, and it is important to get it right. A doctor's first duty is to "Do no harm"!
Furthermore, medicines interact with each other. So one medicine may be less effective, or cause more harm when taken with another medicine.
Falls are more common in people who are on multiple medicines, and these may have serious outcomes. After a fractured hip, for example, one in ten people die within the first month, and three in ten within a year.
And finally, it is easy to end up in a spiral of more and more medicines. Once you start taking a medicine to counteract the side-effects of another medicine, you are on a slippery slope!
What can I do about it?
Work with your doctor and your pharmacist to make sure that any medicines you are on are necessary, and are not causing you more harm than good.
You and your doctor
Ensure you know what each of your medicines is for - ask your doctor to write this down for you on your prescribing list, or add it to the prescription so this information is on the instructions for each medicine. Attend for a medicine review with your doctor at least once a year. You and your doctor together will work through all the medicines on your repeat prescription list, determining for each:
- Is it needed? (What are you taking it for, is it working, is it still necessary?)
- Is it causing any side-effects?
- Are there any risks from taking it long-term?
- Are you on the right dose? Could this be reduced and still be effective?
- Do you need any tests, such as blood tests, to monitor that the medicine is not harming you or that the dose is right for you?
- Does it interact with anything else you are on?
- Do you want to continue taking it?
By asking these questions together regularly, you can ensure that you are on no more medication than is really necessary. It may be possible to stop some medicines and reduce the burden of polypharmacy.
Go through the same process with any non-prescribed medicines you use. Make sure your doctor knows about anything you take regularly that you buy over the counter, as this could also interact with your prescribed medicines.
You and your pharmacist
Your pharmacist is a very useful source of information and advice about medicines. They may often be able to answer questions you have about your medicines and save you having to make an appointment with the doctor. You may also be offered a 'medicines use review' by your pharmacist. This is another way to review all your medicines and if you are using them correctly, and the pharmacist may pick up issues your doctor is not aware of. A medicines use review may involve:
- Checking you know what you are taking your medicines for.
- Checking you know how to take them correctly, and are doing so.
- Checking you are remembering to take the medicines regularly.
- Finding out if you are having any side-effects from your medicines or any difficulty taking them as recommended.
- Making suggestions to you and/or your GP on how to reduce any problems you may have with your medicines (eg, a dosette box if you are having difficulty remembering when to take all the different tablets, or suggesting an alternative if a certain tablet is difficult to swallow or giving you side-effects).
- Checking you are ordering enough of your medicines to take them regularly, and not too many so they are wasted.
- Checking you are happy to continue taking all the medicines you are on.
Polypharmacy isn't all bad. People are living active lives longer than they used to partly because of newer medicines. However, it is important to get the balance right. If medicines are doing more harm than good, it is time to stop them.
Further reading and references
Multimorbidity and Polypharmacy; NICE Key Therapeutic Topic (KTT18), January 2017 - updated February 2018
Martin Duerden et al; Polypharmacy and medicines optimisation: Making it safe and sound, The Kings Fund, 28 Nov 2013
PolyPharmacy Guidance; NHS Scotland
The Challenge of Polypharmacy: From Rhetoric to Reality; Royal College of General Practitioners (RCGP), September 2016
Cooper JA, Cadogan CA, Patterson SM, et al; Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open. 2015 Dec 95(12):e009235. doi: 10.1136/bmjopen-2015-009235.
Masnoon N, Shakib S, Kalisch-Ellett L, et al; What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct 1017(1):230. doi: 10.1186/s12877-017-0621-2.