Evidence-Based Reviews

Managing polypharmacy: Walking the fine line between help and harm

Current Psychiatry. 2003 February;2(2):24-36

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Psychiatric disorders including schizophrenia, bipolar disorder, depression, personality disorders, and substance abuse place patients at higher risk for polypharmacy, as do certain demographic, psychosocial, medication, medical, and neurologic factors (Table 4). Other factors that increase the risk for polypharmacy include:

institutional factors (recent hospitalization, admission to a surgical ward, nursing home placement, home health care, increased number of pharmacies used, increased number of clinics attended, client-centered psychiatric treatment compared with non-client-centered psychiatric treatment)
provider factors (visit to a physician, treatment by general practitioners compared with specialists, increased number of providers, undocumented rationale or diagnosis supporting multiple medication use)
having medical insurance.

Steps to avoiding polypharmacy

By identifying polypharmacy’s risk factors, we may decrease its associated morbidity, mortality, and cost. Steps to follow while prescribing—as represented by the mnemonics SAIL³³ and TIDE—may help you avoid polypharmacy’s negative consequences.

SAIL. Keep the drug regimen as simple as possible. Aim for once-daily or twice daily dosing. Try to simplify complex drug regimens by discontinuing any drug that does not achieve its defined therapeutic goal. For diseases and syndromes with less clear-cut causes, subtracting drugs from a complicated regimen may be more therapeutic than adding another drug. Try to treat multiple symptoms and syndromes with a single drug that may have multiple beneficial effects, rather than treating each symptom or syndrome with individual drugs.

Understand the potential adverse effects of each drug and potential drug-drug interactions. Whenever practical, choose drugs with broad rather than narrow therapeutic indices.

Each prescribed drug should have a clear indication and a well-defined therapeutic goal. Prescribe using evidence-based medicine as much as is practical.

List the name and dosage of each drug in the patient’s chart, and provide this information to the patient.³³ Consider adopting computer data entry and feedback procedures, which have been shown to decrease polypharmacy³⁴ and drug-drug interactions.³⁵

TIDE. In the busy medical practice, writing a prescription signals to the patient that his or her time with the doctor is almost finished. Allow time to address medication issues.

Apply the understanding of individual variability, pharmacokinetics, and pharmacodynamics when prescribing. Review with the patient all prescription and nonprescription drugs and dietary supplements being taken.

Be careful to avoid potentially dangerous drug-drug interactions, especially those associated with serious adverse events such as torsades de pointes.

Educate patients regarding drug and non-drug treatments. Explain potential adverse effects of each drug and potential drug-drug interactions.

Related resources

Applied Clinical Psychopharmacology. www.Preskorn.com
Hansten and Horn’s drug interactions. http://hanstenandhorn.com
FDA Center for Drug Evaluation and Research. http://www.fda.gov/cder/index.html
Arizona Center for Education and Research on Therapeutics. http://www.arizonacert.org

Disclosure

Drs. Werder and Preskorn have served on the speakers bureau of, as consultants to, or as principal investigators for Abbott Laboratories, AstraZeneca Pharmaceuticals, Biovail Corp., Bristol-Meyers Squibb Co., Merck and Co., Eisai Inc., Eli Lilly and Co., GlaxoSmithKline, Hoffman-LaRoche, Janssen Pharmaceutica, Lundbeck, Novartis Pharmaceuticals Corp., Organon, Pfizer Inc., Solvay, Wyeth Pharmaceuticals, and Yamanouchi Pharmaceuticals Co., Ltd.