Polypharmacy, defined as the use of 5 or more medications, is common in elderly patients due to multiple comorbidities. It can lead to negative outcomes like increased adverse drug reactions, costs, and non-adherence. Physicians should regularly review patients' medication profiles and deprescribe unnecessary medications. Pharmacists and patients also play a role in managing polypharmacy through medication reconciliation, education, and adherence support. Guidelines like the Beers Criteria provide guidance on potentially inappropriate medications in older adults. Controlling polypharmacy requires coordination between healthcare providers and patients.

1. POLYPHARMACY
PRESENTED BY-
Dr. Aakanksha Priya
JR-1
Department of Pharmacology
AIIMS, Patna

2. OVERVIEW
Introduction
Classification of polypharmacy
Reasons for polypharmacy
Outcomes of polypharmacy
Economic impact of polypharmacy
Measures to control polypharmacy
Conclusion
Summary.

3. INTRODUCTION
The WHO has predicted that the number of older people (conventionally defined as
≥65 years) worldwide will reach 1.5 billion by 2050.
 This population growth poses significant challenges for healthcare systems, as older
people use a disproportionate amount of healthcare resources (eg, medications).

4. DEFINITION
According to World Health organization(WHO), Polypharmacy is
described as the routine use of five or more medications( that includes
Over-the-counter, prescription and/or traditional and complementary
medications used by a patients).

5. EPIDEMIOLOGY
Most common in Geriatric patients.
Prevalence(India) = 33%.
Prevalence(state wise)-
Uttarakhand = 93.14%
Karnataka = 84.6%
Andaman and Nicobar Islands = 2%.
( Priya S, Gupta NL et al.)

6. CLASSIFICATION OF POLYPHARMACY-I
• Rational use of drugs
Appropriate Polypharmacy/Therapeutic Polypharmacy
• Irrational use of drugs
Inappropriate Polypharmacy/Contra-Therapeutic Polypharmacy
• False reporting of consumption of medication.
Pseudo Polypharmacy

7. CLASSIFICATION OF POLYPHARMACY-II
in DepressionSame- class Polypharmacy
• Two selective serotonin reuptake inhibitors eg- Fluoxetine plus Paroxetine.
In bipolar disorderMulti-class Polypharmacy
• Lithium along with an atypical antipsychotics- eg- Fluoxetine/ olanzepine.
In Depression associated InsomniaAdjunctive Polypharmacy
• Use of Trazadone along with Bupropion/Fluoxetine.

8. CONT….
In Psychosis
Augmentation
• Addition of lower dose of Haloperidol in patients with partial response to Resperidone.
Use of Prescription medications along with OTC
medications and alternative medical therapies.
Total
Polypharmacy

9. REASONS FOR POLYPHARMACY
Appropriate reasons Inappropriate reasons
Elderly/Patients with multiple co-morbid medical
conditions.
Self medications
Hospitalization Doctors change from one medication to other within the
same class, but patients does not stop taking the
previous medication
Medical conditions which requires multiple drug
regimen(eg TB)
Doctors also may have put the patients on brand name
and write the next prescription for a generic drug. The
patients continues to take both without realizing they
are the same medication.

10. HIGH RISK POPULATION
1. Age= ≥85 yrs.
2. Hemodynamically unstable patients
3. Low body weight
4. Females
5. Six or more chronic disease states
6. History of adverse drug reactions.

11. OUTCOME OF POLYPHARMACY
1. Positive Outcome
2. Negative Outcome.

12. POSITIVE OUTCOME
POLYPHARMACY
SYNERGISTIC
COMBINATION
Eg- Hypertension
ADDITIONAL DRUG
IMPROVES OUTCOME
Eg-in myocardial infraction
SUPPLEMENTAL
DRUG IMPROVES ADR
OF THE INITIAL DRUG
Eg- anticholinergic drugs added to prevent
extrapyramidal symptoms
POSITIVE OUTCOME

13. NEGATIVE OUTCOME(most common)
Negative
outcome
Interactio
ns(ADR)
Non
Adherenc
e
Inappropri
ate
treatment
Costly

14. NEGATIVE OUTCOME
Negative
outcome
Functional
status
Cognitive
impairment
Falls
Urinary
Incontinence

15. ECONOMIC IMPACT OF POLYPHARMACY
Increase in medication expenditure.
Higher expenditure on the hospital admission.

16. CONTROLLING MEASURES
Role of Physicians
Role of consumers
Role of pharmacist
Steps taken by WHO

17. ROLE OF PHYSICIAN
Inquire about patient’s medications
history
Rational Prescribing of drugs
Counseling of the patient(consumption,
follow up and ADRs)

18. ROLE OF CONSUMERS
1. One should not be afraid to ask questions(most imp.)
2. The patients should know the name of the medications, its indications, its ADRS,
and drug interactions
3. Brown-Bag it:- patient should take all the prescribed drugs, OTC drugs before
leaving the hospital and should ensure regular follow up.

19. ROLE OF PHARMACIST
1. Hospital pharmacist- review the complete and accurate list of patients
medications.
2. Long- term care pharmacist – to evaluate drug therapy regimens in predominantly
elderly patients.
3. Community pharmacist- preventing the dispensing of unnecessary, inappropriate,
and side effects-prone medication.

20. KEY STEPS FOR ENSURING MEDICATION
SAFETY (WHO)

21. WHO PROGRAMMES ON
POLYPHARMACY
1. OPERAM
2. PRIME- eDS
3. SIMPATHY

22. BEER’S CRITERIA
Originally framed by- Dr.Mark Beers(Geriatrician)
First published by American Geriatrics Society in 1991.
Last updated in 2019.
It contains list of potentially inappropriate medications for use in older age
group(>65yrs) to decrease ADRs.
Intended to be use in all ambulatory, acute, and institutionalized settings of care.

23. American Geriatrics Society Beers Criteria®
for Potentially Inappropriate Medications:
Drugs To Be
Used With Caution in Older Adultsa
Drugs Rationale Recommendation
Aspirin for primary prevention
of cardiovascular disease
and colorectal cancer
Risk of major bleeding from aspirin
increases markedly in older age.
Use with caution in
adults ≥70 years
Dabigatran
Rivaroxaban
Increased risk of gastrointestinal
bleeding
compared with warfarin.
Use with caution
for treatment of
VTE or atrial
fibrillation in adults
≥75 years
Prasugrel Increased risk of bleeding in older
adults;
benefit in highest-risk older adults
(eg, those
with prior myocardial infarction or
diabetes
mellitus).
Use with caution in
adults ≥75 years

24. CONT….
DRUGS RATIONALE RECOMMENDTION
Antipsychotics
Carbamazepine
Diuretics
Mirtazapine
Oxcarbazepine
SNRIs
SSRIs
TCAs
Tramadol
May exacerbate or cause SIADH or
hyponatremia; monitor sodium level
closely
Use with caution
Trimethoprim-sulfamethoxazole Increased risk of hyperkalemia when
used
concurrently with an ACEI or ARB in
presence of decreased creatinine
clearance
Use with caution in
patients on ACEI
or ARB and
decreased
creatinine
Clearance.

25. OTHER CRITERIAS
STOPP- START CRITERIA
DEPRESCRIBING GUIDELINES AND ALORITHMS.

26. DEPRESCRIBING GUIDELINES AND
ALORITHMS

27. CONCLUSION
Polypharmacy has been and always will be common among the elderly
population due to the need to treat develops as patient ages.
Unfortunately with this increase in the use of multiple medications
comes with an increased risk for negative health outcomes such as
higher-healthcare cost, ADEs, drug-interactions, medication non-
adherence etc.
Moreover, it is a preventable problem by implementing the methods to
decrease polypharmacy.

28. SUMMARY
Prevention is better than cure.

30. 1. Determine all medication being taken
2. Identify indication for all medications
3. Identify any potential ADE for all the medications
4. Recommend elimination of all the medication without any therapeutic benefits.
5. Recommend substituting medication with lesser side effects.
6. When possible, select agents with less frequently dosing schedule.
7. Recommend starting with a lower dose and increase it slowly
8. Keep drug regimen as simple as possible
9. Review all medication profiles routinely
10. Encourage patients to follow-up routinely.