Some time ago, a 65-year-old friend of mine sent me a list of his daily medications. For a few years, he had been taking nine tablets a day; a statin, a couple of weight loss drugs, one sleeping pill, a multivitamin with zinc, one Ayurveda tablet for constipation, metformin and a couple of pain medications three to four times a week. Each time he met a doctor who prescribed drugs for some problem or the other, he just added them to his list, without bothering to stop or recheck what he was already taking. He had multiple episodes of hepatitis over the past two years, which were initially thought to be due to alcohol, but when the episodes continued even after he stopped drinking, the doctors realized it was likely due to the drugs he was on, at which point, he stopped all the drugs…his hepatitis improved and he never had another episode…he restarted some of the essential drugs, one drug at a time.
When you ingest more than five drugs daily including Ayurveda and other traditional medicine drugs, it is called polypharmacy [1]. Adverse drug events are a leading cause of death, on par with tuberculosis and malaria [2] and polypharmacy contributes to this by escalating the risk.
Pills and surgery are major pillars of modern medicine. One reason why modern medicine is so successful is because of its reductionism, its ability to reduce all patients to a base common level, to assume they are all the same and to create drugs that can be prescribed to large swathes of people worldwide in the same way. For example, it doesn’t matter what the cause of the fever is…every patient takes paracetamol to bring down the fever and if the fever doesn’t come down in 3 days, takes an antibiotic course (often self-prescribed), a strategy that often helps take care of the problem in the short term, damn the long term consequences. For many patients, modern medicine is like magic…take a pill or injection and get better instantaneously…which is one of the reasons for antibiotic resistance in our country, as I mentioned last week.
This is one reason why a doctor who does not prescribe drugs or give injections is looked at with suspicion. During the second Covid-19 wave, doctors who prescribed a large number of drugs were more sought after than those who told you to stay at home and just take paracetamol and water. Not only that, some doctors who did not want to prescribe a long list of pills would still end up doing so because if they didn’t, the patient would just go to another doctor who was willing to prescribe those drugs. We still don’t know how many people suffered because of adverse reactions to this battery of drugs, as compared to Covid-19 itself.
Over a period of time, as patients get older and see a wide variety of physicians and surgeons for everything ranging from diabetes to hypertension to prostate enlargement, the number of pills that a person takes starts growing, with each specialist doctor prescribing their own set of medicines. In India, it is estimated that 49 per cent of people over the age of 60 [3] are victims of polypharmacy, with 31 per cent taking more than 10 drugs per day (hyperpolypharmacy). Potentially inappropriate medications affect 28 per cent of the population. These are huge numbers.
Some polypharmacy may be wholly appropriate. For example, if the patient is unfortunate to have hypothyroidism, diabetes, hypertension, high LDL levels, Parkinsonism and rheumatoid arthritis, then they might land up with a list of more than 5 drugs. Even then, one physician or caregiver should go through the list with a fine-toothed comb to ensure that each drug is being prescribed only because it is absolutely essential and will not reduce the patient’s life expectancy and will not itself cause harm, or if it does, is still in the patient’s best interest.
Most polypharmacy however is usually inappropriate; duplicate drugs, forgotten drugs (drugs that the patient has forgotten to stop taking), inappropriate drugs, supplements of no or doubtful value, traditional medicine tablets and powders of unknown ingredients from babas and fakirs, etc. Unless there is a family physician or caregiver at home going through each pill and figuring out whether it is required or not, whether it will interact adversely with others or not, the list just keeps growing with each new doctor interaction.
Polypharmacy leads to potentially inappropriate medication use, which in turn leads to reduced lifespan and increased mortality [4].
What does this mean for you and I?
In our quest for a long healthspan, apart from physical activity, sensible eating, good sleep, not falling and fracturing, we also need to be cognizant of issues like polypharmacy, which can potentially and paradoxically cause harm.
If you or a near or dear one, are taking more than five tablets of any kind a day, inclusive of supplements (vitamins, minerals, omega-3, etc) and Ayurvedic, unani or similar traditional medicines, you need to re-examine the entire prescription list, preferably with the help of a doctor, to see what can be deprescribed.
Deprescribing is the act of reducing the number of medicines a person takes, and is a treatment strategy that helps reduce the harm from multiple medicines, which in turn will help you live long, healthy [5]. It is best not to question your doctor about each medicine in an acute or emergency situation, but in a chronic stable environment, it is worth having a conversation about deprescribing and reducing polypharmacy, especially if you or your near or dear ones are taking more than five pills a day.
Footnotes
1. Halli-Tierney AD et al. Am Fam Physician. 2019 Jul 1;100(1):32-38.
2. https://www.who.int/publications/i/item/WHO-UHC-SDS-2019.11
3. Bhagavathula AS, et al. Front Pharmacol. 2021 May 19;12:685518.
4. Muhlack DC et al. J Am Med Dir Assoc. 2017 Mar 1;18(3):211-220.
5. Kua CH et al. J Am Med Dir Assoc. 2021 Jan;22(1):82-89.e3.
Dr. Bhavin Jankharia’s new book “Atmasvasth” available online, dives deeper into this concept. He can provide references for all statements of fact and can be reached at bhavin.mm@gmail.com