In Italy, 66% of adults take over 5 drugs and 1 elderly out of 3 over 10 drugs a year. The Italian Society of Internal Medicine pushes to “have a central ‘direction’, such as that offered by the internist, to protect patients from the risks of a too crowded ‘polypharmacy’, due to the ‘collection’ of many different drug prescriptions , one for each consulted specialist, often in conflict with each other, so as to cause interactions and undesirable effects, which can compromise patient safety “.
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Advances in medicine are not only based on the number of pills prescribed. Sometimes, for the sake of the patient, it is necessary to back down, reducing their ‘polypharmacy’, which means taking more than 5-6 medicines a day, a condition common in at least two-thirds of the elderly, as evidenced by a published American study. on Jama Internal Medicine in 2016. The era of deprescribing he was born in less is more’
This is the message that comes from the experts of Italian Society of Internal Medicine which call for an urgent reflection on the phenomenon of ‘polypharmacy’, that is, on the over-prescription of pharmacological therapies. In Italy, 66% of adults take over 5 drugs and 1 elderly out of 3 over 10 drugs a year. It is therefore necessary to think of guidelines to guide doctors not only to prescribe a drug but also to its ‘de-prescription’, that is when and how it is appropriate to suspend it
Of course, Simi emphasizes, the lengthening of life brings with it various consequences, such as the appearance of chronic pathologies, which are often associated with the same patient, but “having a central ‘direction’, such as that offered by the internist, to protect patients from the risks of a too crowded ‘polypharmacy’, due to the ‘collection’ of many different drug prescriptions, one for each consulted specialist, often in conflict with each other, so as to cause interactions and undesirable effects, which can affect the patient safety “.
“Some studies, conducted as part of the Reposi program (REgistroPOliterapie of the Italian Society of Internal Medicine), a network of Italian internal medicine and geriatrics departments – recalls Giorgio Sesti, president of Simi – have clearly highlighted the phenomenon of polypharmacy and its repercussions. At risk of undesirable effects are mainly people with reduced kidney function, a common condition among the elderly ”.
A study conducted on over 5 thousand patients over 65 in the Reposi register, showed that at least half showed moderate impairment of renal function; 14% severe functional impairment and finally 3% very severe. Among patients with hypertension, diabetes, atrial fibrillation, coronary artery disease, and heart failure, 11% were prescribed drug dosages that were inappropriate with respect to renal function. And in the follow-up, prescriptive inappropriateness was associated with a 50% increased risk of all-cause mortality (OR 1.49).
“66% of adult patients take 5 or more drugs and one in three elderly takes over 10 drugs in a year (OsMed data) – recalls Professor Gerardo Mancuso, national vice president of Simi – and this percentage has consolidated in recent years, causing an increase in the causes of hospitalization for adverse events due to drug interactions. Multiple prescribing of drugs sometimes mitigates or nullifies the benefits and increases complications and mortality. In elderly patients, delirium, falls, hypotension, haemorrhage and other conditions recognize polypharmacy as the cause. De-prescribing pharmacological molecules is an activity that the internist must do in all patients, but especially in the elderly.
“It is necessary to reverse this trend – says Sesti – and usher in the era of ‘deprescribing’. But for this to happen, we must raise the awareness of patients and doctors, especially family members and internists, by inviting them, after a thorough drug history, to ‘thin out’ prescriptions starting with their older patients. The excessive prescription of drugs can cause serious drug interactions and put a strain on the kidneys and liver of the most aged patients, and this phenomenon is beginning to emerge in all its gravity even abroad ”.
“In addition to the Rest program – remembers the teacher Nicola Montano, Vice President and President Elect of Simi – our Company launched its ChoosingWisely campaign in 2016, on the basis of what was happening in the United States, Canada and many European countries. The rationale for this new cultural approach is to sensitize doctors and patients to reduce examinations and treatments that have shown little use and therefore increase patient safety on the one hand, while reducing waste on the other. Our Company was one of the first to implement a multicentre research project, to evaluate the effects of an educational intervention on doctors aimed at reducing some hospital low-care practices, obtaining very promising results, published in 2021 sull’European Journal of Internal Medicine”.
Montano then recalls the slogan less is more ‘laciato da Rita Redbergdirector of JAMA Internal Medicine and professor of cardiology at the University of California, San Francisco: “A slogan, published for life time in 2010, which we could summarize with the concept that ‘doing less is sometimes better than doing more’ for our patients “.
“The lessis more – continues Sesti – is not only valid for medicines, but also for too many tests, some of which (CT scans) for example involve health risks linked to an excess of radiation. A National Cancer Institute article published in Jama Internal Medicine estimated that considering the number of CT scans performed in 2007 it would be reasonable to expect an excess of 60,000 cases of cancer and as many as 30,000 excess deaths. Now certainly, many of these tests may have helped save lives, for example by discovering an early stage cancer. But the vast majority could perhaps have been avoided. So also in this case the watchword is ‘appropriateness’, especially when a ‘risk’ test is prescribed to a young patient ”.
In short, deprescribing, at least conceptually, rests on very solid foundations. Now, however, the doctors will have to go to school to learn how to stop the medicines for their patients, without causing damage. “This is an important paradigm shift – comments Sesti – which mainly involves the sphere of primary prevention, where diet, physical activity and quitting smoking can do a lot, without the need to medicalise a person who is not yet a patient. We must also carefully analyze all the prescriptions made to our patients, especially if they are elderly. It will be easy to see that many can be eliminated; in a subject with a limited life expectancy, upon discharge from the hospital, it would be appropriate to ask oneself which medicines are really needed, eliminating all the others. We believe that on this point it is necessary to organize a consensus that indicates the path to follow in this direction, to guide the work of doctors with a series of shared decisions, aimed at improving prescriptive appropriateness ”.
October 24, 2022
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