To preserve the health of a patient, especially an elderly one, sometimes the drugs are better removed than added. The concept of de-prescribing, alongside that of personalized medicine, is increasingly gaining ground among doctors as a tool to improve the health of the most fragile patients. It was discussed in recent days at the conference organized by the Higher Institute of Health, which brought together the authors of the first Italian guidelines for the management of polytherapy and de-prescribing, in order to spread them more and more in clinical practice.
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What is polytherapy
We talk about polytherapy when a person suffering from different diseases and disorders takes five or more drugs at the same time. It is a condition that mainly occurs among older people. In the 2019 report of the National Observatory on the use of Medicines (OsMed) it is reported that in Italy 29% of men and about 30% of women over the age of 65 use 10 or more substances on a daily basis. Furthermore, the number of drugs progressively increases as we age, in both women and men.
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The problem of drug interactions
Taking many medications at the same time increases the risk of some side effects. Adverse reactions caused by a drug concern the interaction with other drugs, with food, with supplements and with the disease itself. And so it can happen that a drug, instead of helping to improve health, becomes a danger. The probability of events occurring that can also lead to hospitalization increases linearly with the number of drugs taken, up to almost 100% for those being treated with 9 or more substances. In the year examined in the OsMed report, 1.3 million elderly people took drug combinations at risk of causing kidney damage, for example, and over 900,000 took combinations at risk of causing gastrointestinal bleeding.
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A multidimensional approach
The recommendations and guidelines for the treatment of multimorbidity and pharmacotherapy of 2021 therefore emphasize the need to adopt a multidimensional approach to the therapeutic strategy, which takes into account the patient’s life expectancy, the effective possibilities of treatment and the health goals of the patient. patient himself. Preserving the patient’s well-being means, in the case of polytherapy, knowing how to optimize all these aspects, suspending – where necessary – one or more therapies after an agreed administration period. The problem, he explains Graziano Onderdirector of the Department of Cardiovascular, Endocrine-Metabolic and Aging Diseases of the ISS and Scientific Director of the event, is that for each drug the recommendations on when to prescribe it are known, but not on when to stop it.
InterCheck: a site and an app
However, discontinuing a drug is not a trivial matter. It is often a difficult and gradual process, which must also address the fears of doctors and patients about the consequences on health and the course of the disease that it must treat. It is therefore important to choose in the appropriate way which is the right drug to eliminate because it is “inappropriate” compared to the others, and responsible for adverse reactions. To help in this process, some IT tools have been developed such as InterCheck, a prescription support system developed by the Mario Negri Institute for Pharmacological Research. Through a website and an app, doctors can retrieve useful information on the undesirable effects of drugs, on the risk categories based on the pathologies found, on the dangerous combinations, on the recommended dosage and also on the suspension mode. According to a study published in Drugs AgingInterCheck has been shown to be effective in significantly reducing inappropriate drug prescriptions for RSA guests, where 86% of the elderly were exposed to dangerous drug interactions.
The riskiest drugs
Among the most valued drugs when it comes to suspension and de-prescription, some deserve particular attention, because they are more likely to cause adverse reactions. In the OsMed report and in the recommendations listed among the guidelines for the management of polytherapy we find anti-inflammatory drugs of the NSAID category, anticoagulants, gastroprotectors and proton pump inhibitors. All of these increase the risk of gastrointestinal bleeding, especially in old age, where the use of these drugs is very common. According to the numbers of the report, in fact, in Italy there are about 910,000 people over 65 who take two or more drugs at the same time that increase the risk of gastrointestinal bleeding.
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In addition to these, statins are also mentioned, used to lower the level of fats in the blood and to be suspended if the patient’s life expectancy is less than one year; or vitamin D, a supplement to be used only in people with osteoporosis at high risk of bone fractures and not as a preventive measure, or drugs that act on a neurological level and on mood, but can cause loss of lucidity and injuries. The message? For the patient, especially if elderly, it is important to have the support of a multi-professional team that takes care of assessing the state of health and the frailty index, and that periodically reviews all the drugs taken, deciding when it is time to remove instead of to add.