How many pills are too many?

The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.

The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.

Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.

Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.

Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarised in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalisation or death.

About one-third of adverse events in hospitalisations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 4,00,000 preventable adverse drug events in hospitals each year, costing $3.5 billion.

One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable. Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk, because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20% take 10 or more drugs or supplements.

Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug.

One study found that 44% of frail, older patients were prescribed at least one drug unnecessarily. A study of over 2,00,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60% of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomised trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35%. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a programme that included a review of medications.

Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomised trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

Inappropriate dosage
So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately.

Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review.

Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications which I am on that I don’t need anymore, or that I could try going without?'”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.