Polypharmacy: why taking multiple medicines needs close monitoring

Deepina Pal, 26, has been living with chronic kidney disease since she was 16 and has been on dialysis for nine years. She takes about 10–12 different kinds of medicines every day for multiple autoimmune and other chronic conditions, including medicines for blood pressure, cholesterol, thyroid and heart conditions, as well as migraine and other problems. Some need to be taken three times a day.She sets alarms and records her medicines on her phone. When she was first prescribed medication for blood pressure, she became extremely drowsy and slept for long periods. Her family later understood that her blood pressure was falling. For people on dialysis, regular blood tests can lead to changes in medication.Deepina’s experience reveals an important factor when it comes to taking many medications: the number of medicines does not, by itself, mean that treatment is inappropriate. The safety concern is whether every medicine remains necessary, effective and suitable as a person’s health changes.Multiple conditions, several medicinesPolypharmacy is generally described as the regular use of five or more medicines; the use of 10 or more is often termed hyperpolypharmacy. It is particularly common among older people living with multiple chronic conditions, although complex treatment regimens can occur at any age.A review of 27 studies involving 11,649 older adults in India found pooled rates of polypharmacy and hyperpolypharmacy of 49% and 31%, respectively.“Not every case of polypharmacy is inappropriate,” says S. Manicka Saravanan, consultant, geriatric medicine, Apollo Hospitals, Greams Road, Chennai. A person living with diabetes, hypertension and heart disease, for example may need several medicines. The concern only arises when medicines no longer have a clear benefit, duplicate one another, interact adversely or create a treatment burden that outweighs their benefit.The World Health Organization identifies medication safety in polypharmacy as one of its priority areas under its Medication Without Harm initiative.The risksSmitha Jain, consultant, internal medicine, SIMS Hospital, Chennai, says problems can arise when medicines prescribed by different specialists are considered separately rather than as one treatment plan.A patient may inadvertently receive duplicate medicines, particularly when several doctors prescribe for different conditions. Drug combinations can also cause harm. Some medicines used in heart failure or for blood pressure can affect potassium and kidney function; antifungal drugs can interact with anti-epileptic medicines, while some combinations can increase blood-thinner levels and the risk of bleeding.Taking an extra dose can also be dangerous. An additional diabetes medicine may cause hypoglycaemia, while missing certain medicines, such as anti-epileptic drugs, can trigger seizures.Older adults are particularly vulnerable because age-related changes, kidney or liver impairment, frailty, cognitive problems and multiple illnesses can alter how medicines are handled by the body. Side effects such as low blood pressure, low sodium, dizziness and confusion can increase the risk of falls.Review and safety checksA medication review should ask why each medicine was started, whether it is still needed, whether the dose remains appropriate, and whether there are side effects or interactions, says Dr. Saravanan. Kidney and liver function, nutrition, cognition, mobility, falls risk, cost and difficulties with swallowing or complex timings should also be considered.Doctors recommend that patients bring all their medicines to appointments, a “brown bag” review can uncover duplicate prescriptions as well as over-the-counter, herbal or alternative products that doctors may not know about.An updated medication list should be shared between specialists, particularly after hospitalisation or a change in treatment. Pharmacists can also help identify interactions and dosing problems. Pill organisers and alarms may reduce missed or repeated doses.Some medicines may eventually be reduced or stopped when their benefits no longer outweigh their risks. This process, known as deprescribing, should be done carefully and not by stopping medicines abruptly. Electronic prescribing systems can flag some interactions and duplicate medicines, but clinical judgement remains the most important.The aim is not simply to reduce the number of medicines, but to ensure that each one has a clear purpose and that the overall treatment remains safe as the patient’s circumstances change.