The 10 Commandments of Polypharmacy

I work with patients, nurses, doctors, pharmacists and other healthcare professionals everyday who struggle with medication management. One of the biggest problems I run into is polypharmacy. Ten, twenty, even sometimes up to 30+ medications is something I come across on a daily basis. Here is my top ten ways that healthcare professionals can help minimize polypharmacy.

1. Thou shalt not start, ask for, dispense, or administer a medication without reviewing a medication list that is accurate, up to date, and complete with over-the counter medications and supplements

2. Thou shalt consider utilizing non-drug approaches and interventions to solve patient problems before initiating medication

3. Thou shalt assess if a medication is effective before adding a new medication for the same condition

4. Thou shalt consider any new symptom is an adverse effect of another medication until proved otherwise

5. Thou shalt not start a medication without an appropriate indication and assessing appropriate lab work

6. Thou shalt identify limits for medications not intended for chronic use as well as not continue a medication indefinitely for symptoms that have an expected short duration

7. Thou shalt not start a medication from a similar medication class without appropriate rationale

8. Thou shalt not initiate a medication without considering medications that may treat duplicate conditions – Kill two birds with one stone

9. Thou shalt consider eliminating or reducing medications at every medication review

10. Thou shalt be willing to accept risk in discontinuing a medication if they were willing to accept the risk of initiating a medication

Thanks for reading!  I’m giving away a 6 page PDF on 30 medication mistakes I see in my practice as a clinical pharmacaist, please take advantage of the free and unique opportunity!

17 Comments

  1. Kate Robinson

    Your 10 commandments of polypharmacy is very black and white in my opinion and i remember when i was doing my training feeling similar to what you have expressed. However, i am now much older with low back and hip problems which require a number of medications for relief of pain etc. using your ideology it scares me somewhat to think that should i not be able to speak for myself how i may be left feeling! Remember that pain is what the patient says it is not what we as individuals think it should be. I know that i could discuss this issue in some depth but maybe better left here.

    Reply
    • John Mountzuris

      Kate, I myself also has severe pack pain and knee pain but to think that everything is solved by adding more medication to ones profile is no sound treatment. The 10 suggestions listed above does not take away from treating patients effectively but it only asks that we treat patients more thought into the process rather than just keep adding more and more drugs to a patients drug treatments.
      Just look at elderly patients who are practiced 35+ medications, do you honestly believe and 85 year old patient living alone is able to remember to take all 35 meds?

      Reply
  2. chri1599

    Appreciate the comment and absolutely respect your viewpoint. Making clinical decisions is NOT black and white, and it takes an entire team judging the risk versus the benefits of each medication. This list is meant to help healthcare professionals ask difficult questions prior to adding meds, so when a medication is necessary we can feel comfortable in that decision. There are many other considerations that are not in this list, but wanted to give you an idea of some of the biggest issues I see. Too frequently a medication is the first option given without a second thought. I see a lot of “collateral damage” done by medications, and these commandments are meant to try to minimize that, not to prevent patients from getting necessary medications. – Thanks for reading!

    Reply
    • gopinath

      Really a good work. Thank you so much for the guidelines. At the same time I would like to add a point that ‘Step up’ and ‘step down’ on drug dose especially for chronic diseases, although a mention about the limit of drug application in point 6. It also helps optimizing the therapy while review the medication chart.
      with regards

      Reply
      • chri1599

        Appreciate that – Thanks!

        Reply
        • jabow4

          Good road map! Start low, go slow and LISTEN!

          Reply
  3. Luka Tehovnik

    Excellent guidelines! As you already mentioned, it is not so black and white as others might think. Listening to the patient is crucial and I believe we as a pharmacists do a great job in this area.

    Reply
  4. Cheryl Hill BSRN

    I work in LTC and see polypharmacy A LOT! Many of these older folks are on ten to thirty medications a day. Many of these medications are prescribed to offset symptoms from the other medications! I never see physicians trying to lower dosages or discontinue meds unless there is someone else to start complaining and pushing the issue, usually the patient (if they can) or a family member who finds out how many meds Mom or Dad is on and starts asking questions.

    Reply
  5. G.K. Sheshagiri

    The chain of reactions your ten commandments has activated reminds me of my own experience as a of a close relative of a patient with multiple ailments having a strong belief in taking a medicine for any symptom of a pain or discomfiture. This naturally results in poly pharmacy due to much obliging prescribers with total disregard to drug-drug and drug- food interactions. I remain a mute spectator unable to prevail upon the patient against consuming a fistful of tablets & capsules at least twice a day (of course on prescription!) despite my professional knowledge. This tendency, I find , is prevalent in the population and not confined to oldies as opined in one of the comments. Who will bell this cat? your ten commandments might, perhaps!!!

    Reply
    • chri1599

      In the worst of the worst cases I’ve seen they generally involve a patient and doctor who both like to utilize medications for every symptom! – Great comment!

      Reply
  6. Lisa Teat

    Fantastic synopsis of guidelines that should be used on all my patients. Thanks!

    Reply
    • Eric Christianson

      Thanks Lisa!

      Reply
  7. dwight Overturf,rph

    I noticed they are starting to be much tougher in the medicare area about repeat hospital admits for the same thing.And they my not cover (medicare people) it at the hspital.Pharmacists can help in this polypharmacy area so that reasonable , easy to remember med. treatments are in place and to follow so that repeat admits do not happen and the patient is not hit with a huge hospital bill medicare will not cover.

    Reply
  8. Chad

    Great ideas, except #6. There’s too little understanding and sympathy by physicians and especially insurance (and ESPECIALLY Medicare) of chronic conditions that “should” be short-term in most patients, yes, but are clearly chronic and important conditions for many patients: GERD, migraines, pain, insomnia The drug therapies for these are too often limited to the severe detriment of the patient, so then other meds have to be added to fill the treatment gaps forced upon these patients. I’ve seen a limit on a PPI of #90 per 365 days, triptans limited to 9 per month, zolpidem limited 30 per 90 days, ondansetron limits… Sure, there’s prior authorizations… That leaves the patient sleepless, barfing, and eating nothing but TUMS for two weeks. These people are wrecks, with no other diagnosis or explanation besides idiosyncratic, and it’s sad that they’re made to suffer by bureaucrats.

    Reply
  9. Vanessa Tomm

    Hello Eric! Thank you so much for your books, youtube videos, and guide for BCMTMS preparation. I am reaching out because I cannot find the youtube video on this article from your channel and also tried googling it. You provide examples in each commandment. I really want to share the video with my residency and previous ambulatory care pharmacist. I think it’s great to orient students and residents to this line of thinking.

    Reply
    • Eric Christianson

      Hey Vanessa, thank you so much for the message and kind words! – Here’s the link to the video; may have to put this on my list to upgrade on the audio etc. haha! https://www.youtube.com/watch?v=WWdEzFWTnCU

      Reply

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Written By Eric Christianson

April 27, 2014

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