Polypharmacy: When too many medicines become a health risk

By Dr Tariq Jagnarine

Fam Med, Global Health

For many people, taking medication every day is an important part of staying healthy. Someone living with diabetes, high blood pressure, heart disease, arthritis, or other chronic conditions may genuinely need several medicines.
But as the number of medications increases, so does the possibility of something going wrong.
This is where we need to talk about polypharmacy.
Polypharmacy generally refers to the use of multiple medications – often five or more – at the same time. However, the number alone does not determine whether treatment is inappropriate. A person may need eight medicines and benefit from every one of them, while another may be taking three medicines that interact or are no longer necessary.
The real question should therefore be:
Does this person still need every medicine they are taking, at this dose, in this combination?

How does polypharmacy happen?
It often develops gradually.
A patient sees one doctor for diabetes, another for a heart condition and perhaps another for arthritis. Medicines are added over several years. Prescriptions are renewed, but older medications may never be reassessed.
Then we sometimes encounter what is called a prescribing cascade.
Imagine that a medication causes ankle swelling. Instead of recognising the swelling as a side effect, another medicine is prescribed to treat it. That new medication produces another symptom, and yet another treatment is added.
Before long, the medicine cabinet becomes increasingly complicated.
Over-the-counter medicines, vitamins, herbal remedies and supplements can add another layer because patients may not always consider these to be “medications” when speaking with their doctor.

Why does it matter?
The more medications someone takes, the greater the potential for:
• Drug interactions
• Dizziness and falls
• Low blood pressure
• Kidney or liver problems
• Bleeding
• Confusion or excessive sleepiness
• Difficulty remembering doses
• Taking the wrong medication or dose
Older adults are particularly vulnerable because the body’s ability to process medicines changes with age.
Kidney and liver function may decline, body composition changes, and the brain may become more sensitive to certain medications. A dose that was appropriate several years ago may therefore need reconsideration.

“Doctor, can I stop some of these tablets?”
It is an important question, but do not stop prescribed medicines suddenly without professional advice.
Some medications can cause serious problems if abruptly discontinued.
Instead, ask for a medication review.
Bring every medicine you use to the appointment. These include prescription tablets, inhalers, injections, eye drops, painkillers, vitamins, herbal preparations, and supplements.
This simple exercise is sometimes called a “brown-bag review.”
Your doctor or pharmacist can then ask:

What is this medicine for?
Is it still needed?
Is the dose appropriate?
Are two medicines doing the same thing?
Could one medicine be causing another symptom?
Are there dangerous interactions?
Can the treatment be simplified?

Deprescribing: Sometimes less is better
Modern medicine is very good at starting treatments. We also need to become equally good at reviewing when they should be reduced or stopped.
This process is known as deprescribing.
Deprescribing does not mean randomly removing medicines. It is a planned and supervised process of reducing or stopping medications when the potential harm outweighs the benefit or when they are no longer necessary.
The goal is not to achieve the smallest possible number of tablets.
The goal is safe, effective and appropriate treatment.
Five questions every patient should ask
Whenever a new medicine is prescribed, consider asking:
1. Why am I taking this medicine?
2. How long should I take it?
3. What side effects should I watch for?
4. Does it interact with my other medicines or supplements?
5. When will we review whether I still need it?
Keeping an updated medication list on your phone or in your wallet can also be extremely helpful, particularly during emergencies or when seeing a new healthcare professional.
In primary care, we often care for patients over many years. As conditions accumulate, prescriptions can accumulate with them.
Sometimes one of the most useful things we can do during a consultation is not prescribe another tablet.
It is to stop and review.
When I see someone taking several medications, I want to know not only “What else does this patient need?” but also “What may this patient no longer need?”
That conversation becomes particularly important for our older patients and those living with several chronic diseases.
Medicines save lives. But every medication should have a purpose, and that purpose should be periodically reassessed.
If you or someone you care for takes several medications every day, don’t panic – and don’t stop them on your own.
Instead, periodically ask your doctor or pharmacist for a complete medication review.
Know what you take.
Know why you take it.
Know when it should be reviewed.
Because good healthcare isn’t about taking more medicine.
It’s about taking the right medicine, at the right dose, for the right reason, for the right amount of time.