drug drug interactions in polypharmacy related irrational prescribing....

1. Abstract:
This study aimed to estimate the prevalence of poly pharmacy, the use of antibiotics and
nutritional supplements and to determine the factors affecting poly pharmacy in different age
limits of patients. The study of pharmacoeconomics and evaluation of the safety and efficacy
parameters including drug/drug interactions.A retrospective cross sectional study of
prescriptions of hospitalized and community pharmacy patients were carried out in Lahore
and Faisal Abad.
100 prescriptions were collected (43% were female patients and 57% male patients). The
prevalence of poly pharmacy (patients who take ≥5 medications) at hospitals and community
pharmacy was 40%. 19% patients were calculated taking nutritional supplements. The
community pharmacy prescriptions were 75% and hospitalized prescriptions were 25%.
17% drug-drug interactions were calculated. The % of drug interactions of each
pharmacological class was (NSAIDs (34%), (Antihypertensive (34%), antibiotics (10%),
antifungal (8%), ant diabetics (8%) and Supplements 5%).
The cost of therapy per prescription per day was 174.70/PKR. About half of elderly patients
are exposed to poly pharmacy. A portion of geriatrics used nutritional supplements. The
factors that were associated with patient’s exposure to poly pharmacy were different diseases
including diabetes, hypertension Heart Diseases, Joint pains and GIT infections.

2. INTRODUCTION:
Polypharmacy is an untoward iatrogenic process .The use of multiple interacting medications is a
costly and common problem in all age limits, mostly in elderly patients. A number drug-drug
interactions and use of supplements are major problems in polypharmacy. There is a pure need of
clinical interventions to reduce polypharmacy related all these issues including appropriateness
of indications and drug-drug interactions (1).The concurrent therapy of multiple medicines with
nutritional supplements Indicates specific problems in all age groups, mostly in elderly patients.
Elderly patients are the largest consumers of medications up to 50% suffer from chronic
diseases. The increase in number of prescribed medicines and supplements may increase risk of
adverse effects, drug-drug or Drug-disease interactions. Finally the pharmacoeconomic Factors
should also be considered (2). Poly pharmacy concerns with safety of medications also
associated with risks of adverse drug reactions, undesirable drug-drug interactions,
hospitalization, medication non adherence, poorer quality of life and premature mortality.poly
pharmacy may also be essential for treatment of multiple co morbid health conditions, in other
cases it represent in appropriate prescribing, which represents a clinical and economic burden for
both patient and society (3).The high prevalence of co morbid conditions such as diabetes,
hypertension, depression, gastrointestinal problems and joint diseases leads to prescribe a variety
of medicines and experience poly pharmacy. According to recent study there is a lack of
consensus on the methods used to study poly pharmacy including measurements, definitions of
poly pharmacy and study samples associated with analytical methods(4).
Although there is no clear consensus on the definition of poly pharmacy, one of the most
commonly used definition is the concurrent use of 5 or more drugs. This study lacks examining
factors associated with poly pharmacy to understand why the prevalence of poly pharmacy
differs within age limits. The factors associated with poly pharmacy may include older age,
female gender, low education, poor self-reported health, high number visits to health
professionals(5)
“Concurrent use of many different drugs “or “Excessive use of drugs” or
“The use of an excessive number of inappropriate drugs or
“The use of a number of drugs in excess of that which is clinically indicated”(6).
The study shows that polypharmacy is unavoidable in elderly patients, so it is important to assess

3. and evaluate drugs use patterns in older adults that are at high risk of potential consequences of
polypharmacy.
A poor response to treatment causes prompt physician to prescribe more than one medications to
enhance the clinical effects. The relatively high proportion of poly pharmacy gives an advantage
over monotherapy, in terms of safety and efficacy, is a matter of debate. This study has not
confirmed any clinical benefits resulting from treatment with combination of more than 5 drugs.
The safety of poly pharmacy may increase the risk of metabolic syndrome and other adverse and
side effects. Furthermore the patients treated with poly pharmacy has higher risks of drug-drug
interactions .Poly pharmacy causes a rise in cost of therapy per day (7).
To improve the knowledge of medication prescribing and utilization that is clinically associated
with polypharmacy in community and hospitalized patients.
Most desirable approach for measuring and monitoring drug uses to evaluate the prescribing
patterns, to monitor and improve prescribing patterns in order to make medical care more
rational and cost effective(8).
Furthermore knowledge of the most frequent features of patients with a high risk of exposure to
poly pharmacy can help practitioners to avoid the potentially harmful effects of these
prescriptions. In addition an improved understanding of medication patterns among older adults
may assist health care providers in providing optimal care to patients(9).
Although polypharmacy may be unavoidable in the elderly if disease and comorbidities are to be
treated appropriately, it is important to assess drug and nutritional supplement products use
patterns in an older adult population at risk of the potential consequences. We carried out this
study with the following objectives:
 To estimate the prevalence of polypharmacy and nutritional supplement use;

4.  To identify factors associated with exposure to polypharmacy (10).
The study of prescribing patterns seeks to evaluate, monitor, and improve prescribing patterns in
order to make medical care more rational and cost-effective. Furthermore, knowledge of the
most frequent characteristics of patients with a high risk of exposure to poly pharmacy can help
practitioners to avoid the potentially harmful effects of these prescriptions (11).
The prescribing of medicines is rapidly increasing in all aging populations where evidence based
guidelines are encouraging more prescribing of preventive treatments. However with increasing
co- morbidity, clinical decision making is more difficult because positions and patients both
struggle to balance the benefits and risks of multiple recommended treatments. Mostly
prescribers that are involved in extra care of a patient there exist greater prevalence of
inappropriate prescribing. Clinical interventions to avoid poly pharmacy, such as pharmaceutical
care may result in significant improvement(12).
Aims and objectives
To determine potential drug drug interactions after evaluation of patient’s prescription
Evaluation of cost per prescription
LITERATURE REVIEW:

5. i) Howard M. Fillit, MD; Robert Futterman, Lawrence Sunbow, MD; Gloria P. Picariello,
RN; Eileen C. Scheye, MBA; Randall K. Spoeri, PhD and John L. Roglieri, MD had
examine the effects of medication reviews by primary care physicians on prescriptions written
for elderly members of a Medicare managed care organizations that were at risk for
polypharmacy. Study Design was Prospective study .they have screened 37,372 elderly
members, 5737 (15%) were at risk for polypharmacy. Of these 2615 (46%) responded to the
follow-up survey. Of the survey respondents, 1087 (42%) had gone to their primary care
physician for a medication review. During the review, 96% of patients discussed their
prescription medications and 72% discussed nonprescription medications they were taking.
Twenty percent reported that their physician discontinued medications, 29% reported that the
physician changed the dose of a medication, and 17% informed their physician about a new
prescription or nonprescription medication (12).
Robert J. Constantine, PhD; Timothy Boaz, PhD; and Rajiv Tan don, MD had reviewed
Over the past decade, antipsychotic polypharmacy has increased markedly in the United States
among adult patients with schizophrenia and related disorders. Although varying definitions and
methodologies make comparisons difficult, antipsychotic polypharmacy has been reported in
25% to 50% of adults with schizophrenia in inpatient settings and in 5% to 25% of patients in
ambulatory settings. Increased expectations for recovery and the belief that second generation
antipsychotics are better tolerated may have helped to stimulate prescribing of ≥2 concurrent
antipsychotic medications. However, unclear benefits, heightened concerns about excessive
dosing, an increased risk for metabolic abnormalities, and other adverse effects have necessitated
a closer look at the practice (13).
Rhita Bennis Nechba , Moncif El M'barki Kadiri , Mounia Bennani-Ziatni, Amine Ali Zeggwagh had
reported the pharmacological treatment of older adults with cognitive impairment represents a
challenge for prescribing physicians, and polypharmacy is common in these complex patients.
The aim of the current study is to assess prevalence and factors related to polypharmacy in a
sample of nursing home (nursing home) residents with advanced cognitive impairment.
Polypharmacy status was categorized into three groups: non polypharmacy (zero to four drugs),
polypharmacy (five to nine drugs), and excessive polypharmacy (more than10 drugs).
Polypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was

6. Seen in 245 (16.9% (14).
IV) John D. Gilbert a, Ian F. Musgrave b, Claire Hoban b, Roger W. Bard
had studied short treatment for irritable bowel with the following herbs: Astragals propinquus,
Codonopsis pilosula, Peoria sp., Atractylodes microcephaly, Pueraria sp., Poria cocoa, Dioscorea
opposita, Patronize, Psoralea corylifolia, Alpine katsumadai, Glycyrrhizin uralensis and
Dolomite solei sp. a 43-year- old woman developed acute severe liver failure requiring liver
transplantation. Histo pathological examination of the liver showed massive hepatic necrosis in
keeping with drug/chemical toxicity. While numerous studies have evaluated the effect of
polypharmacy. As this case demonstrates that fulminant hepatic failure and death may be caused
by the concomitant use of a number of herbal products, the possibility of untoward effects from
herbal polypharmacy must be increasingly considered in the evaluation of medico legal
cases(15).
v) S.H. Zyoud ,A.B. Abd-Alhafez, A.O. Hussein , I.S. Abu-Shehab, S.W. Al-Jabi and
W.M. Sweileh. They have aimed to estimate the prevalence of polypharmacy, polyherbacy and
nutritional supplement use and to determine the factors affecting polypharmacy in geriatric
patients. A prospective cross-sectional study of a group of hospitalized patients was carried out
at Al- Wattani governmental hospital, Nablus, Palestine. Participant demographics and
information about the current use of prescribed medications, herbal products and nutritional
supplements were collected. The prevalence of polypharmacy (patients who take >5
medications) at hospital discharge was 51%. Eighty participants (26.7%) reported taking two or
more herbal products (polyherbacy). Thirty-six participants (12.1%) reported taking two or more
vitamins/mineral supplements. About half of elderly patients are exposed to polypharmacy at Al-
Watani hospital. Also, a portion of geriatrics used herbal product and nutritional supplements.
The factors that were associated with patient’s exposure to polypharmacy were: living with
family, diabetes mellitus, heart failure, general weakness, and joint pain. Interventions to reduce
the high-level polypharmacy in the elderly during their stay in a government hospital in Palestine
should focus more on patients with diabetes mellitus, heart failure, and joint pain (2).
vi) Syed Imran Haider, ZahidAnsari, Loretta Vaughan, Helen Matters and Eric Emerson

7. This study fills a void in research in polypharmacy and associated factors, and provides a high
quality and reliable data for planning service delivery in both the health and disability services;
has direct application to evidence-based policy development and strategic planning across the
government departments, disability service providers, health service providers and the wider
community; and informs policy development and medication safety and quality activities. Some
population groups with ID may be exposed to higher levels of adverse effects of medicines,
while at the same time having impaired capacity to protect themselves from the harmful effects
of these medicines (16).
vii) Jan Jaracz, Edyta Tetera-Rudnick, Dominika Kujath, Agnieszka Raczyn´ ska,
Sebastian Stoszek Wojciech Czernas, Piotr Wierzbinski f, Adam Moniakowski g, Krystyna
Jaracz and Janusz Rybakowski have studied the concurrent use of two or more antipsychotic
drugs in schizophrenia. The aim of this study was to investigate the range of APP in
schizophrenic patients discharged from psychiatric units in Poland, and to determine its
demographical and clinical correlates. Data on the pharmacological treatment of 207 patients
with a diagnosis of schizophrenia, discharged from six psychiatric hospitals from September–
December 2011 were recorded by experienced psychiatrists. Clinical and demographical
information was obtained on each patient. The severity of symptoms at admission, and their
improvement during hospitalization were assessed using the Clinical Global Impression Scale.
Results: At discharge, 52.7% of the patients were prescribed one, 42.5% two and 4.8% three
antipsychotic drugs (AP). When two AP were applied, it was usually a combination of two
second generation antipsychotics (SGA) (46%), or of both first generation antipsychotics (FGA)
and SGA (48%). The SGA’s olanzapine and risperidone were those most commonly prescribed.
Patients treated with two or more AP had a higher number of previous hospitalizations than
patients receiving antipsychotic monotherapy. Mood stabilizers were prescribed for nearly one
third of the patients, while antidepressants and benzodiazepines were prescribed for fewer than
10%. Conclusions: The prevalence of polypharmacy in Poland is similar to that reported in other
countries (17).
viii) Alessandra Iurlo, Anna Ubertis, Silvia Artuso, Cristina Bucelli, Tommaso Radice,
Manuela Zappa, Daniele Cattaneo, Daniela Mari and Agostino Cortelezzi have studied that

8. Older patients’ comorbidity and polypharmacy can significantly influence the success of the
treatment, as well as the cognitive and psycho-social aspects. A significant proportion of chronic
myeloid leukemia (CML) patients are “elderly”: in the past the aim of therapy in this subset of
patients was only to contain the leukemic mass, but nowadays, with the advent of the protein-
tyrosine kinase inhibitors, also elderly patients can access these treatments. We want to assess if
even old CML patients, with a correct geriatric evaluation, can be successfully treated with
protein-tyrosine kinase inhibitors(18).
ix) Davide L. Vetranoa, Matteo Tosatoa, Giuseppe Colloca, Eva Topinkova,Daniela
Fialova,Jacob Gindin, Henri€ette G. van der Roest, Francesco Landia, Rosa Liperoti
Roberto Bernabei andGraziano Onder
Conducted a cross-sectional analysis of 1449 nursing home residents with advanced
Cognitive impairment participating to the Services and Health for Elderly in Long Term Care
(SHELTER) project, a study collecting information on residents admitted to 57 nursing home in
eight countries. Polypharmacy status was categorized into three groups: non polypharmacy
(Zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy was
observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%).
Compared with non polypharmacy, excessive polypharmacy was associated directly with
ischemic heart disease. Polypharmacy and excessive polypharmacy are common among nursing
home residents with advanced cognitive impairment. Determinants of polypharmacy status
include not only comorbidities, but also specific symptoms, age, and functional status (19).
x) Howard M. Fillit, MD; Robert Futterman, PhD; Burton I. Orland, RPh; Terrence Chim,
RPh; Lawrence Susnow, MD; Gloria P. Picariello, RN; Eileen C. Scheye, MBA; Randall K.
Spoeri, PhD; John L. Roglieri, MD; and Samuel W. Warburton, MD. We conducted a study
to demonstrate the prevalence of polypharmacy (defined as receiving 5 or more prescription
medications during the 3-month study period) among Elderly members of our managed care
organization. Two years later, elderly members identified as being at risk for polypharmacy were
sent a letter encouraging them to schedule a medication review with their primary care physician.
Each primary care physician was provided with clinical practice guidelines on polypharmacy and
patient-specific medication management reports. Patients and physicians were subsequently
mailed a survey to assess the impact of the medication review program on prescribing practices.
During the review, 96% of patients discussed their prescription medications and 72% discussed

9. nonprescription medications they were taking. Twenty percent reported that their physician
discontinued medications, 29% reported that the physician changed the dose of a medication, and
17% informed their physician about a new prescription or nonprescription medication they were
taking (20).
Chapter No 03 material and method

10. 3.1 Study design:
This was the retrospective and cross sectional study involved 100 prescriptions that were
collected from hospitalized and community patients of Lahore and Faisalabad regions.
3.2 Sample size:
The assuming average number of prescriptions that were collected from community and
hospitalized patients of Lahore and Faisalabad regions is 100 prescriptions. This number was
used as a guide to calculate sample size needed for this study. A convenience sample of 100
prescriptions’ was collected between September and October 2014.
Sample technique:
First of all, a sampling frame was prepared and then with simple random technique sample of
100 prescriptions was selected including both community and hospitalized patients.
Inclusion and exclusion criteria:
The inclusion criteria for patients were:
Hospitalized and community patients aged 30 to 70 years old, willing to participate in the study.
Patients who were (>30 or <70) years old excluded from the study.
Operational definitions:
For the purpose of the study, certain operational terms were defined poly pharmacy was defined
as the use of multiple medications by a patient, generally older adults (those aged over 65
years).More specifically, it is often defined as the use of five or more regular medications.
Medication was defined as any substance used for treatment or prevention of disease.

11. Methodology:
The retrospective cross sectional study was conducted among the community and hospitalized
patients. For this purpose 100 prescriptions were collected including both community and
hospitalized patients. Data was collected through quantitative and statistical analysis.
Then calculate the percentage prevalence of polypharmacy, percentage usage of antibiotics,
percentage prevalence of nutritional supplements, and percentage of drug-drug interactions in all
prescriptions.
Separately calculate the percentage of prescriptions of male and female patients and calculate
The average cost of prescription per day among the community and hospitalized patients to
evaluate the pharmacoeconomics.

12. RESULTS:
TOTAL NO: OF PRESCRIPTIONS TAKEN IN STUDY WERE 100.
1) NO: OF MALE AND FEMALE PATIENTS IN DIFFERENT AGE GROUPS:
(TABLE:1)
Age limits No: of patients No: of female patients No: of male patients
30-34 9 4 5
35-38 16 8 8
39-42 12 5 7
43-46 18 8 10
47-50 20 9 11
51-54 6 2 4
55-58 4 1 3
59-62 5 2 3
63-66 2 1 1
67-70 8 3 5
TOTAL 100 43 57

13. Table: 2 Percentage of the antibiotic classes usedin all age limits
% OF MALE
PATIENTS
57%
% OF FEMALE
PATIENTS
43%
% OF MALE AND FEMALE PATIENTS
AGE LIMITS NAME OF ANTIBIOTICS ANTIBIOTIC CLASS
30-34 VIBRAMYCIN Tetracycline
CEFIXIME 3rd generation
cephalosporin
LEVOFLOXCACINE 2nd generation
flouroquinolone
CLINDAMYCINE Lincomycin class
SULFAMETHOXAZOL Protein synthesis
inhibitor
TRIMETHOPRIM Protein synthesis
inhibitor
AZITHROMYCINE Macrolide
METRONIDAZOL ANTIPROTOZOAL
35-38 CEFUROXIME 2nd generation

14. cephalosporin
METRONIDAZOL ANTIPROTOZOAL
CIPROFLOXACINE 2nd generation
flouroquinolone
LEVOFLOXACINE 3rd generation
flouroquinolone
TOBRAMYCIN penicillin antibiotic
MOXIFLOXACINE 4th generation
cephalosporin
CEFTRIAXONE 3rd generation
cephalosporin
AMOXICILLINE penicillin antibiotic
CEFIXIME 3rd generation
cephalosporin
METRONIDAZOL antiprotozoal
39-42 CEFTRIAXONE 3rd generation
cephalosporin
AMOXICILLINE penicillin antibiotic
METRONIDAZOL ANTIPROTOZOAL
43-46 AMOXICILLINE penicillin antibiotic
OFLOXACINE 2nd generation
flouroquinolone
CIPROFLOXACINE 2nd generation
flouroquinolone
METRONIDAZOL antiprotozoal
CLARITHROMYCINE Macrolide
CEFACLOR 2nd generation
cephalosporin
47-50 CEFTRIAXONE 3rd generation

15. cephalosporin
FLAGYL METRONIDAZOL
CEFUROXIME 2nd generation
cephalosporin
METRONIDAZOL antiprotozoal
51-54 CIPROFLOXACINE 2nd generation
flouroquinolone
METRONIDAZOL ANTIPROTOZOAL
AMOXICILLINE penicillin antibiotic
CEFTRIAXONE 3rd generation
cephalosporin
55-58 GENTAMYCIN Nitro imidazole antibiotic
CLARITHROMYCIN Macrolide
METRONIDAZOL ANTIPROTOZOAL
59-62 CIPROFLOXACIN 3rd generation
cephalosporin
METRONIDAZOL ANTIPROTOZOAL
63-66 AMOXICILLINE penicillin antibiotic
CIPROFLOXACINE Flouroquinolones
67-70 LEVOFLOXACINE Flouroquinolones
AMOXICILLINE penicillin antibiotic
MOXIFLOCACINE 4th generation
cephalosporin
CEFTRIAXONE 3rd generation
cephalosporin
METRONIDAZOL ANTIPROTOZOAL

16. 3) % of the antibiotic classes usedin all age limits:
4)Names ofthe supplements used in patients:
(TABLE: 3)
Sr
no:
Name of supplement Active ingredients
34%
24%
19%
16%
5%
2%
% OF ANTIBIOTICS USED IN AGE LIMITS
CEPHALOSPORINS (32%)
METRONIDAZOL (23%)
FLOUROQUINOLONES (18%)
PENICILLINS (15%)
FOLIC ACID SYNTHESIS INHIBITOR
(5%)
TETRACYCLINES (2%)

17. 1 VITAMIN K1 Phytonadione
2 FEFOL FOLIC ACID+CALCIUM
3 alpha keto acid Histidine, L-Tyrosine, L-lysine, nitrogen & calcium.
4 Surbex-z Nicotinamide:100mg, Riboflavin (Vitamin B2):15mg, Thiamine
HCl (Vitamin B1):15mg, Tocopherol (Vitamin E):30IU, Zinc
Oxide:22.5mg, Ascorbic
Acid:500mg,Cyanocobalamin:12mcg, Folic
Acid:150mcg, Pyridoxine:20mg]
5 Polybion-z Nicotinamide:50mg, Riboflavin (Vitamin B2):15mg, Thiamine
HCl (Vitamin B1):15mg, Ascorbic
Acid:300mg,Cyanocobalamin:10mcg,Pyridoxine:10mg
6 INDROP-D VITAMIN D
7 Iberet folic Ferrous Sulphate:525mg,Nicotinamide:30mg, Riboflavin
(Vitamin B2):6mg, Thiamine HCl (Vitamin B1):6mg, Ascorbic
Acid:500mg, Calcium
Pantothenate:10mg,Cyanocobalamin:25mcg, Folic
Acid:0.8mg, Pyridoxine:5mg
8 Maltofer syrup Iron Hydroxide Poly Maltose Complex:50mg/5ml
9 Osteo d Alfacalcidol 0.5mg
10 Avemar Silicon dioxide, maltodextrin,fructose,sodium chloride
11 Myfol Folic acid
12 Ferfix-F Folic Acid:0.35mg, Iron Hydroxide Poly Maltose
Complex:100mg
13 Divasas Nicotinic Acid:20mg, Retinol (Vitamin A):5000IU, Riboflavin
(Vitamin B2):1.7mg, Thiamine HCl
(VitaminB1):1.5mg, Tocopherol (Vitamin E):30mg, Ascorbic
Acid:60mg, Calciferol:400IU,Cyanocobalamin:6mcg, Iron
Salts:18mg, Iodine:150mcg,Magnesium Oxides and
Hydroxides:100mg,Pyridoxine:2mg,

18. 14 QALSAN -D Calcium Carbonate:1250mg, Cholecalciferol:125IU
15 Bevidox Thiamine HCl (Vitamin
B1):100mg/3ml,Cyanocobalamin:1000mcg/3ml,Pyridoxine:100
mg/3ml]
16 cremafinn Paraffin:1.25ml/5ml, Magnesium Oxides and
Hydroxides:3.5ml/5m
17 Sangbion Manganese:0.2mg,Cyanocobalamin:7.5mcg, Folic
Acid:1mg, Copper:0.2mg
18 CAL-C Calcium Lactate, Ascorbic Acid:, Calcium Carbonate:
19 Trihemic Tocopherol (Vitamin E):30IU,Ascorbic
Acid:600mg,Cyanocobalamin:25mcg, Folic Acid:1mg, Ferrous
Fumarate:350mg
5) % prevalence of nutritional supplements:
7)% of prescriptions with and without supplements:
% prevalence of nutritional supplements
% of patients using
supplements
% of patients not
using supplements

19. 8) % of drug-drug interactions in prescriptions:
% OF PRESCRIPTIONS WITH AND WITHOUT
SUPPLEMENTS
PRESCRIPTIONS WITHOUT
SUPPLEMENTS(81%)
PRESCRIPTIONS WITH
SUPPLEMENTS(19%)
17%
83%
% OF DRUG-DRUG INTERACTIONS IN
PRESCRIPTIONS
PRESCRIPTIONS WITH D-D
INTERACTIONS(17%)
PRESCRIPTIONS WITHOUT
D-D INTERACTIONS(83%)

20. 9) % OF INTERACTIONSOF DIFFERENTPHARMACOLOGICAL
CLASSES:
Drug-Drug INTERACTIONS: (TABLE: 4)
ALL OF THE DRUG-DRUG INTERACTIONS ARE ASSESSED FROM TEXTBOOK
Sr
no
Drug - Drug interaction mechanism Significa
nce level
Out put Management
1 Ciprofloxacin +calcium
supplements
GI absorptionof
QUINOLONESmaybe
decreased.
2 Decreased
pharmacologic
effects of
QUINOLONES
Concurrent use cannot be
avoided.
34%
34%
10%
8%
8% 5%
1%
% OF INTERACTIONS OF DIFFERENT
PHARMACOLOGICALCLASSES
NSAIDs(34%)
ANTIHYPERTENSIVE(34%)
ANTIBIOTICS(10)
ANTIFUNGALS(8%)
ANTIDIABETICS(8%)
SUPPLEMENTS(5%)
OTHERS(1%)

21. 2 aspirin+ glimepiridine Aspirinreducesbasal
glucose levelsand(↑es)
insulinsecretionalso
inhibitionof prostaglandin
synthesismayinhibit
insulinresponsesto
glucose.
2 ↑es hypoglycemic
effect
Monitor the patient's blood
glucose.If hypoglycemia
develops,consider decreasing
the SULFONYLUREA dose
3 ASPIRIN+DICLOFENAC
SODIUM
Competitive inhibitionof
the acetylationsite of
cyclooxygenaseinthe
platelet.
1 ↓es
cadioprotectivity
and ↑es gastric
irritation via aspirin
SELECT analgesics that do not
interfere with antiplatelet effect
(eg, acetaminophen).
4 NORTRIPTYLINE+LEV
OFLOXACIN
MECHANISMIS
UNKNOWN
1 may (↑es) torsades
de pointes
Other quinolone antibiotics that
do not prolong the QTc interval
(USED)
5
ASPIRIN+PROPRANOLOL
SALICYLATESmay inhibit
biosynthesisof
prostaglandinsinvolvedin
the antihypertensive
activity
2
may (↓es) activity
of propranolol
Monitor BP. If an interaction is
suspected, consider lowering
the dose of the SALICYLATE
6 FLUCONAZOL+STEROIDS Inhibition of
CORTICOSTEROID
metabolism(CYP3A4) and
decrease inelimination.
2 may ↑es toxicity of
steroids
Closely monitor patients for
CORTICOSTEROID adverse
effects. Adjust dose as needed
7 LOSARTAN+FLUCONAZO
L
inhibitionof metabolism
(CYP2C9) of LOSARTAN by
FLUCONAZOLE
3 may ↑es
antihypertensive
effects
Closely monitor blood pressure
responseto LOSARTAN when
FLUCONAZOLE is started,
stopped, or changed in dosage
8 METHOTREXATE+MEFE
NAMIC ACID
Reducedrenal clearance is
suspected.
1 may ↑es MTX
toxicity
Monitor for renal impairment
that could predisposeto MTX
toxicity
9 ASPIRIN+PROPRANOLOL SALICYLATESmay inhibit 2 may (↓es) activity Monitor BP. If an interaction is

22. biosynthesisof
prostaglandinsinvolved in
the antihypertensive
activity
of propranolol suspected, consider lowering
the dose of the SALICYLATE
10 piroxicam and
acetaminophen with
(ALENDRONATE)
NSAIDsand
BISPHOSPHONATESmay
be synergisticwithrespect
to causinggastric ulcers.
3 ↑es risk of gastric
ulceration
Use caution when co-
administeringthese agents
11 OMEPRAZOL+CYANOCO
BALMIN
OMEPRAZOLE-induced
hypohydriaor
achlorhydriamay
decrease the absorption
of vitaminB12.
5 MAY
(↓es)therapeutic
action of
VITAMIN B12
If both drugs are to be given
chronically,consider
administeringVITAMIN B12
parenteraly.
12 ASPIRIN+OMEPRAZOL (PPI) mayincrease in
gastric pH resultsina
more rapiddissolution
and release of
SALICYLATE.
3 may (↑es)gastric
side effects
Patients at risk of serious
gastric disordersdueto the
releaseof SALICYLATES in the
stomach should avoid
concurrent use of these
agents.
13
Aspirin+captopril
DUE TO Inhibitionof
prostaglandinsynthesis
MAY
(↓es)hypotensive
and vasodilator
effects of the ACE
INHIBITOR
Adjust ASPIRIN dosage to less
than 100 mg/day; convert to
non-aspirin antiplateletagent;
or continue ASPIRIN and
convert patient from ACE
INHIBITOR to angiotensin-
receptor blocker.
14 Aspirin+insulin The serum glucose-lowering
actionof INSULINmaybe
potentiated.
2 acute INSULIN
response to a
glucose load is
enhanced
Monitor blood glucose
concentrations and tailor the
INSULIN regimen as needed.

23. 15 ASPIRIN+RINGER
LACTATE
Urine alkalization leads to
increased renal clearance and
reduced serumlevels of
SALICYLATES
3 Renal clearance of
SALICYLATES
increases
dramatically above
urine pH 7.
The patient receiving
concurrent URINARY
ALKALINIZER and anti-
inflammatory SALICYLATE
therapy may require higher
than expected SALICYLATE
doses
16 CLARITHROMYCIN+OME
PRAZOL
CLARITHROMYCIN may
inhibit the metabolism
(cytochrome P450 3A4 and
2C19) of OMEPRAZOLE,
3 MAY(↑es)
concentrations of
CLARITHROMYC
IN and
OMEPRAZOLE
no special action isneeded. Co
-administration of these
agents may be beneficial in the
treatment of Helicobacter
pylori
17 ATENOLOL+AMINOPHYL
INE
Pharmacologic antagonism.
BETA-BLOCKERS may
reduce demethylation of
THEOPHYLLINE.
2 MAY (↓es)
elimination of
THEOPHYLLINE
Monitor plasma
THEOPHYLLINE levels when a
BETA-BLOCKER is added or
deleted from a regimen
10) Average Cost of 100 prescriptions = 17468/100 = 174.70
AVERAGE COST/PRESCRIPTION/DAY = 174.70
11) AVERAGE NO: OF DRUGS PRESCRIBED= 420/100 = 4.20
12) % OF PRESCRIPTIONS:
13) Prevalence of polypharmacy:
75%
25%
% OF TYPES OF PRESCRIPTIONS:
COMMUNITY PHARMACY
PRESCRIPTIONS(75%)
HOSPITAL ADMITTED
PRESCRIPTIONS(25%)

24. 40%
60%
% prevalence of polypharmacy
(patients who take ≥5
medications) 40%
(patients who take <5
medications): 60%

25. Discussion:
The estimates of the prevalence of polypharmacy vary, often because of the differences in
definitions of the number of medications that must be taken to constitute poly pharmacy. This
study estimates the prevalence of poly pharmacy, drug-drug interactions and nutritional
supplements. The current study showed that the percentage of patients who were taking five or
more than five medications was 40 percent, the risk of inappropriate use of antibiotics,
supplements and other medicines in community living and hospitalized patients has been
described and analyzed in drug-drug interactions.
All of our study findings indicate that hospitalization did not lead to a reduction in the number of
drugs taken .In contrast; it led to an increase in the prevalence of poly pharmacy. This suggests
that most disorders effecting elderly people are a chronic and need sable therapy. In addition,
hospitalization leads to new diseases diagnosis that requires further drugs or more new and
complex therapy.
According to our results NSAIDs and antihypertensive were the most commonly used
medications. In this study, the factors that were significantly associated with patient’s exposure
to poly pharmacy were diabetes mellitus, hypertension, general weakness and joint pains. There
are many clinical factors associated with polypharmacy in the elderly, some diseases such as
hypertension, diabetes mellitus and diseases associated with pain were significantly co related
with poly pharmacy.
One of the purposes of the current study was to analyze the prevalence of nutritional
supplements use in all age limits. The major strength of the study is that it is the first one in
Lahore that presents data on the prevalence of poly pharmacy and nutritional supplements used
among hospitalized and community elderly patients. Therefore the results of this study will be
important in the optimization of health care practices.

26. Over all, this study was subject to a few limitations. Firstly, our results may not be generalized to
the entire population of Lahore. Additionally, it was difficult to track certain relationships with
poly pharmacy. For example adverse drug reactions and non-adherence.
Furthermore the study was not designed to evaluate the appropriateness of the drug therapy or
any adverse clinical outcomes resulting from polypharmcay.

27. Conclusions:
About 40% patients were exposed to polypharmacy in community and hospitalized patients. The
calculated percentage of drug-drug interaction is 17%. The percentage prevalence of nutritional
supplements is 19%.

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