This document discusses polypharmacy, which is defined as the administration of many drugs simultaneously or an excessive number of drugs. Polypharmacy is common in elderly patients with multiple chronic conditions. It can be appropriate if all drugs achieve therapeutic objectives and minimize adverse effects, but is often inappropriate if drugs are unnecessary or cause harm. Tools like Beers Criteria, STOPP, and START can help identify inappropriate polypharmacy and guide deprescribing. The document outlines factors contributing to polypharmacy and consequences like adverse drug reactions, providing strategies to assess medication benefit-harm and safely discontinue unnecessary drugs.

1. Discussion
Poly-pharmacy
Dr. Prashant Shukla
Dept. of Pharmacology
GMC Patiala

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POLYPHARMACY
*Haider SI, Johnell K, Thorslund M, Fastbom J (2007). "Trends in polypharmacy and potential drug-
drug interactions across educational groups in elderly patients in Sweden for the period 1992 -
2002". International Journal of Clinical Pharmacology and Therapeutics 45 (12): 643–653
*Prevalence:
around40%

4. Definition
 Polypharmacy, defined by the WHO as
"the administration of many drugs at the
same time or the administration of an
excessive number of drugs“.
 It is frequent among the elderly as they
often suffer from chronic diseases with
concomitant pathologies.
 Synonyms: “polymedication”,
“polyprescription”, “multimedication”,
“multiprescription”.
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5. Unifying Theory/ Concept
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6. Inappropriate polypharmacy is present,
when one or more drugs are prescribed
that are not or no longer needed
because:
a) there is no evidence based indication,
the indication has expired or the dose
is unnecessarily high
b) one or more medicines fail to achieve
the therapeutic objectives
c) one, or the combination of several
drugs cause unacceptable ADRs. 6

7. Appropriate polypharmacy is present,
when:
(a) all drugs are prescribed for the purpose
of achieving specific therapeutic
objectives
(b) therapeutic objectives are actually being
achieved or there is a reasonable
chance they will be achieved in the
future
(c) drug therapy has been optimized to
minimise the risk of ADRs
(d) the patient is motivated and able to take7

8.  Pill burden is a term that refers to the
number of pills(tablets or capsules, the
most common dosage forms) that a
patient takes on a regular basis, along
with all associated efforts that increase
with that number - like storing,
organizing, consuming, and
understanding the various medications
in one’s regimen.
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9. Polypharmacy contributory
factors
Patient related factors:
1. Age
2. Multimorbidity
3. Intellectual disability
4. Acute hospitalization
5. Health care visits
Healthcare related factor:
1. Multiple providers
2. Medication errors
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Patient
Related
Factors
Polypharmacy contributory
factors

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Doctor
Related
Factors
Polypharmacy contributory
factors

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Healthcare-related Factors:
Polypharmacy contributory
factors

13. 1. Administration of 2 to 4 medications as
"minor polypharmacy”.
2. The use of ≥ 5 medications as "major
polypharmacy”.
 Newer terms:
1. ‘Hyperpolypharmacy‘ or 'excessive multi-
medication' is used to designate the
consumption of ≥10 medications.
2. The consumption of ≤5 medications
considered as "non-polypharmacy" or
"oligopharmacy"
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Types of Polypharmacy

14. 1. Same-Class Poly-pharmacy- Use of more than one
medication from the same class ( 2 SSRI’s).
2. Multi-Class Poly-pharmacy - Use of more than one
medication from different classes for the same
symptom cluster (ACEI + CCBs).
3. Adjunctive Poly-pharmacy- Use of one medication
to treat the side effects of another medication from a
different class (Antibiotics+ Probiotics+
Multivitamins).
4. Augmentation Poly-pharmacy- Use of one
medication at a lower dose along with another
medication from a different class in full therapeutic
dose for the same symptom cluster. 14
Types of Polypharmacy

15. Types of Polypharmacy
 Polypharmacy can be simultaneous,
cumulative or continuous.
1. Simultaneous polypharmacy corresponds
to the number of drugs concurrently taken
by a patient on a given day.
2. Cumulative polypharmacy is defined by
the sum of different medications
administered over a given period of time.
3. Continuous polypharmacy takes into
account medications present in two given
time periods spaced by an interval of six
months. 15

16. Tested indicator of measuring
polypharmacy
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17. Polypharmacy consequences
1. Adverse drug reactions
2. Drug-drug interactions
3. Non Adherence/ Decreased
medication compliance
4. Unnecessary drug expenses
5. Poor quality of life, Outcomes
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18. Tools to Help Decrease
Polypharmacy
 Beers Criteria
 STOPP Criteria
 START Criteria
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Table 1: Potentially
Inappropriate Medication Use in
Older Adults
Table 1I: Potentially
Inappropriate Medication Use in
Older Adults Due to Drug/
Disease or Drug-Syndrome
Interactions That May
Exacerbate the Disease or
Syndrome
Table III: Potentially

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24.  Screening Tool of Older Persons’
potentially inappropriate
Prescriptions (acronym, STOPP): 68
draft criteria
 Screening Tool to Alert doctors to
Right (i.e. indicated, appropriate)
Treatment (acronym, START): 22
draft criteria
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29. Deprescribing protocol
 It is comprises 5 steps:
1. ascertain all drugs the patient is currently taking
and the reasons for each one;
2. consider overall risk of drug-induced harm in
individual patients in determining the required
intensity of deprescribing intervention;
3. assess each drug in regard to its current or future
benefit potential compared with current or future
harm or burden potential;
4. prioritize drugs for discontinuation that have the
lowest benefit-harm ratio and lowest likelihood of
adverse withdrawal reactions or disease rebound
syndromes;
5. implement a discontinuation regimen and monitor
patients closely for improvement in outcomes or
onset of adverse effects.
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Deprescribing protocol…
BROWN BAG
ANALYSIS

31. Summary
Polypharmacy in elderly is a necessary
evil. Although it is not always
inappropriate, but the
“inappropriateness” should be judged
on a case to case basis.
Necessary tools should be used to avoid
it.
And deprescribing is recommended to
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32. References
1. Monegat M, Sermet C. Polypharmacy:
Definitions, Measurement and Stakes
Involved Review of the Literature and
Measurement Tests. Questions
d’économie de la santé. 204 – 2014
Dec.
2. Mount sinai Hospital. Geriatrics.
Polypharmacy and Polymorbid
Patients: Practical Tips and Tricks.
2013, Nov.
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33. Thank you for your patience!!
33
Adjunctive
polypharmacy
??