Dr. Benjamin Franklin mused that, “the best doctor gives the least medicines.”
Some 200-plus years later, his words still ring true. Data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey indicate that prescription drug use is on the rise.
Nearly 60 percent of survey participants reported use of a prescription medication in the last 30 days in the most recent survey. Meanwhile, among those surveyed, nearly 20 percent reported use of five or more prescription medications. This is sometimes referred to as polypharmacy, and it is especially a concern among the elderly.
As people age, their metabolism changes and, along with it, the processing of medications by the body. Such processes include changes in medication absorption, drug distribution throughout the body and drug clearance from the bloodstream. Each individual drug carries additional risk of adverse effects for the elderly, but this risk rises with the number of medications prescribed. Similarly, over-the-counter and herbal medications can likewise increase the risk of adverse effects.
This does not mean that all medications are bad or that combinations of medications should be avoided in older people. It does mean that extra care is needed to assess and monitor the necessity of medications on an ongoing basis, carefully considering such factors as duration of treatment, need for the medication and when the risk of the medication exceeds its benefit.
These considerations have led to the concept of “de-prescribing,” first introduced in the 1990s and now becoming more commonplace in the contemporary practice of medicine. De-prescribing is the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving health outcomes.
The process of de-prescribing begins with what I recently referred to as a “brown bag check-up” in which all medications and supplements are collected for a visit with a medical provider or pharmacist. Each medication is carefully reviewed to determine its proper dose, current indication, likelihood of benefit and potential risk of adverse effects.
This is ideally followed by an honest discussion with the patient about the relative benefits and risks of each medication and prioritization of those most likely to provide the greatest benefit. This often permits identification of drugs for which a trial of discontinuation can be considered.
Reasons to de-prescribe include lack of benefit, adverse reactions, patient non-use of the prescribed medication, resolution of the condition for which the medication was prescribed and recent addition of a drug that interacts in a negative way.
Studies have shown that patients on multiple medications are commonly open to discussions about reducing medication use and that, for the vast majority of patients, such efforts are safe and effective in reducing risk from adverse drug effects.
If you are taking five or more medications, talk to your doctor about whether de-prescribing may be right for you.
Dr. Matthew A. Clark is a board-certified physician in internal medicine and pediatrics practicing at the Ute Mountain Ute Health Center in Towaoc.