Polypharmacy is defined as taking five or more medications daily. It is not surprising that one survey1 found more than 50 percent of Medicare patients had five daily prescriptions; 12 percent of these patients were prescribed ten or more medications.
It is essential that every opportunity is taken to reduce the number of medications prescribed to a single patient. A review of medications can help avoid unnecessary side effects, negative drug interactions and wasted money. Below are some medications that may warrant careful analysis of the benefits and risks before continuing to click the refill button on your prescribing software.
Evidence is accumulating that indicates the long-term use of PPIs is not as safe as many assume. Chronic use of these acid-suppressing medications has been implicated in reduced absorption of calcium (leading to fractures), Vitamin B12, and thyroid hormone, as well as increased risk of Clostridium difficile infection and acute and chronic kidney infection. While some patients do require long-term use of PPIs, they are not indicated for many patients who have been using them for years (i.e., GERD, started as stress ulcer prophylaxis while hospitalized, etc). When no longer indicated, PPIs should be tapered very slowly over the course of weeks (to prevent rebound reflux) and can be replaced as needed with the use of an H2 receptor-blocker (such as ranitidine, famotidine, or others) or an antacid, such as chewable calcium carbonate.
Even though the guidelines for prevention of endocarditis were changed in 19972, antibiotics continue to be prescribed before dental procedures for patients with prosthetic joints despite there being no evidence to support this practice. In 2015, the American Dental Association guidelines specifically discourage this practice.3
Benzodiazepines and “Z” Drugs (zolpidem, zaleplon, and eszopiclone) come with a risk of falls, and therefore should be avoided in older adults.4, 5 Some patients may be on multiple medications that can increase the risk of falls, and these effects can potentiate each other, leading to a very real risk of a fall and fracture.
In a 2017 study, one-third of adults who had been diagnosed with asthma had normal respiratory tests (spirometry / peak flow) and were successfully weaned off of asthma medications.6 Authors found that not using spirometry to make the original diagnosis was most often the source of the diagnostic error. Similar rates of misdiagnosis of asthma have been found in other studies as well. 7, 8
The evidence of benefit is insufficient to recommend the use of muscle relaxants for the treatment of subacute or chronic low back pain.9 These medications cause many adverse effects (especially when combined with alcohol) and can be particularly dangerous in older adults.
There is little evidence that statins are beneficial when prescribed for primary prevention in patients older than age 75.10, 11 Additionally, many statins have well-documented drug interactions, making the risk clearly outweigh the benefits. While the benefits are well established for secondary prevention, the risks and benefits of continuing a statin for primary prevention in adults over 75 years should be carefully evaluated.
This drug class offers modest benefits and sometimes significant side effects. For every patient who receives a modest benefit from this drug, 11 patients receive no benefit. 12 In addition to lack of efficacy, side effects of these medications can include weight loss, nausea, syncope and urinary incontinence. 13, 14