How much is polypharmacy a necessary evil?

A few years ago, I and some GP colleagues – Tony Avery from Nottingham University, and Rupert Payne from Cambridge University – were asked to do a review of polypharmacy by the King’s Fund. Polypharmacy had always been looked on disparagingly through my training in medicine and my subsequent work as a GP. It was clear from our review that this high-minded perspective of polypharmacy was no longer valid.

Polypharmacy has become common place and the stark evidence is that we now have three times more people taking ten-or-more drugs than was the case in the late 1990s. The reasons for this are complex; many more people take preventative drugs for things like high blood pressure and lipid-lowering; we have a plethora of guidelines urging us to use treatments, and there are an increasing number of drugs available. Perhaps the biggest issue now and in the future is the sheer number of people in middle age who are getting older and frailer and carrying many diseases into old age – the so-called ‘multimorbidity challenge’.

Polypharmacy is a necessary evil for many of these people and drugs can be used to reduce symptoms and potentially increase longevity. However, this does mean that we need to get smart and change the way we practice. Giving people lots of medicines can disrupt their lives and create a burden of medicines taking; something we may impose on them without thinking. The likely result is that medicines are not taken ‘as the doctor ordered’. This means we need to rationalise regimes and try to determine which medicines are essential and give best ‘bangs for the buck’. Shared decision making and medicines optimisation comes to the fore, alongside the enhanced role of practice pharmacists. Polypharmacy can do harm by causing drug interactions and guidelines rarely recognise this but see diseases from the blinkered perspective of the single disease. We need better guidelines which cater for common co-morbidities – something that NICE is working on. We need better, pragmatic research that looks at outcomes from drugs in older people with complex disease – research that is rarely done by drug companies. We need tools that help us rationalise drug choices – for example, the PINCER indicators that highlight unsafe prescribing.

Perhaps the biggest challenge is that we need to reconsider how general practice is organised. For medication reviews, and reconciliation of medicines when patients move between hospitals, home and other care settings, we need to work much more closely with our pharmacist colleagues and recognise their skills in supporting medicines use. Personal care with continuity provided by a named doctor becomes very important, alas something that has waned with the increasing workload of general practice. As our population ages, we really need more GPs and more resources feeding into community care, but this may be pie in the sky at a time when politicians, the media and the public seem much more interested in technological advances and the cutting edge of new medicines used in specialist settings.

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