Risking health, safety, hospitalization for too many medicines. A paradox? Not exactly. Rather an effect of polypharmacy, or polypharmacy or polypharmacy, in short, of that phenomenon which in Italy affects at least two thirds of the elderly and which consists in the intake of more than 5-6 medicines a day, even in conflict with each other, prescribed by different specialists that do not speak to each other. Cardiologists, endocrinologists, general practitioners and other professionals focused each on the pathology of their competence but a little less on the interactions between medicines or on the appropriateness of a prescription in a specific patient, which is a context, an ecosystem and not a single disease . So much so, that one in 11 hospitalizations for elderly patients can be traced back to a wrong prescription or side effects of drugs or drug interactions. For Simi, the Italian Society of Internal Medicine, which is meeting in Rome these days for its 123rd congress, it is time to thin out the medicines that are prescribed. That is, it is time to de-prescribe.
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Less is more, or limiting polypharmacy
“Studies conducted as part of the REPOSI program (Simi’s Political Therapy Register), a network of Italian departments of internal medicine and geriatrics, have clearly highlighted the phenomenon of polypharmacy and its repercussions – he says Giorgio Sesti, president Simi -. It is necessary to reverse this trend and usher in the era of deprescribing “.
Or of less is more, to use the term borrowed from architecture (roughly translatable with less is better) and used for the first time in medicine by Rita Redberg, present at the Roman scientific event. Professor of cardiology at the University of California at San Francisco Redberg is director at Jama Internal Medicinethe journal that already in 2016 published a study on drug interactions to conclude that 15% of the elderly are potentially at risk of a major drug-drug interaction.
Who is most at risk: the kidney problem
At risk of side effects due to polypharmacy are in particular people with reduced kidney function, a common condition among the elderly. According to a 2021 survey published in Drugs Aging out of more than 5,000 patients over 65 in the REPOSI registry at least half showed moderate impairment of renal function, 14% severe functional impairment and 3% very severe.
Among those with hypertension, diabetes, atrial fibrillation, coronary artery disease, and heart failure, 11% were prescribed medication dosages that were inappropriate with respect to kidney function. And in the follow-up, prescribing inappropriateness was associated with a 50% higher risk of all-cause mortality.
Delirium, falls, hypotension, bleeding
“66% of adult patients take 5 or more drugs and one in three elderly takes over 10 drugs in a year, according to OsMed data – recalls Gerardo Mancuso, national vice president of SIMI – a percentage that 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 (a disorder of attention, of the cognitive state and of the level of consciousness that is generally reversible, ed), falls, hypotension (blood pressure that is too low, ed), bleeding and other conditions, have as their cause the polytherapy. Deprescribing pharmacological molecules is an activity that the internist must do in all patients, but especially in the elderly “.
Too much radiation. Even in young people.
But it’s not just for medicines, the Less is more formula. For internal medicine doctors, too many tests are prescribed, some of which, for example, CT scans 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, an increase of 60,000 cases of cancer and 30,000 excess deaths could be expected. “Now, certainly many of these tests could have helped to save lives, for example by discovering a tumor at an early stage. But the vast majority – is Sesti’s consideration – could perhaps have been avoided”.
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First: prevent
But how do you avoid prescribing medicines and tests? Deleting therapies for patients who are often elderly and fearful, and afflicted with multiple chronic conditions could be complicated … “It is clear that we are talking about an important paradigm shift – Sesti continues – which mainly involves the sphere of primary prevention, where diet, physical activity and smoking cessation can go a long way, without the need to medicalize those who are not yet patient “. As if to say: before eliminating medicines, we should avoid getting to the need to prescribe them, focusing on a healthy lifestyle.
Second: delete. Via benzodiazepines, fans & Co
But de-prescribing means critically and periodically re-evaluating all prescriptions to eliminate those most at risk such as benzodiazepines, antidepressants, non-steroidal anti-inflammatory drugs, opiates, proton pump inhibitors, various supplements or those that are not strictly useful.
Periodically review prescriptions: avoid prescriptive inertia
Being able to review the presecrections, this sounds a bit like a good intention, but also a difficult strategy to implement, even given the tight deadlines that doctors are able to dedicate to their patients, and which probably will not lengthen. in the next future. “It might seem utopian – is Sesti’s comment – but it is necessary. And on the other hand, prescriptive inertia, that is, the one that leads to repeat prescriptions year after year without a critical re-evaluation, is not a winning strategy. According to a recent analysis, one in 11 hospitalizations of elderly patients can be traced back to a wrong prescription or to the side effects of the drugs “.
Address lines are needed
But “on the de-prescription it is necessary to organize a consensus”, adds Sesti. That is, it is necessary “to think of shared guidelines, which can guide doctors in prescribing appropriateness and in deciding how and when to suspend a therapy. Our company is engaged in the collection of data and in the production of technical material in this sense. “.
Director of complexity
But who is it that has to de-describe? Who is the doctor who has to pull the strings, so to speak, of the patient’s overall situation, and possibly cross out or re-evaluate the therapies? “There are two levels of complexity – explains Sesti – A first level is the competence of the general practitioner. The professional of the second level of complexity, that is polytherapy and more complicated situations, is an internist who works a bit like a director of ‘orchestra, or a director, of complexity and comorbidity “.
Cut prescriptions by 25% in one year: less is more in the world
Polypharmacy is certainly not a national issue. Deprescription is spoken of in the world, at least in the high-income world. The American Society for Post-acute and Long Term Care has launched the ‘Drive to deprescribe’ campaign to which over 4,500 US healthcare facilities have joined so far, and which aims to optimize drug prescribing in patients hospitalized after acute events or in Rsa . The general objective? Reduce the number of prescriptions by 25% within one year. Other followers of deprescribing are US experts from the National Institute on Aging who launched the US Deprescribing Research Network in 2019. Another deprescibing network has been created in Canada, offering scholarships and seminars to study the subject. Meanwhile, the number of publications on deprescribing is increasing year by year. In short, the era of less is better has begun, it seems.