Received: 9 July 2019 Revised: 2 September 2019 Accepted: 25 November 2019
DOI: 10.1002/pds.4942
LETTER TO THE EDITOR
Extreme polypharmacy: The need to mint a new term
The increasing number of drugs that are released annually to the mar-
ket and their progressive use in people who have multiple morbidities,
which is promoted by clinical practice guidelines to achieve control
goals based on demonstrated health results, has led to an increasing
number of patients with polypharmacy. Polypharmacy has previously
been defined as the use of 5 or more medications,1,2 and the concept
of excessive polypharmacy, which is the use of 10 or more medica-
tions, has been added.3 In studies conducted by this research group,
we found a prevalence of excessive polypharmacy of approximately
108.4 per 100 000 people. It was also found that many patients
were receiving 20 or more medications monthly (average 20.1 ± 4.5
drugs per patient), which lead us to propose that there is a new cate-
gory of polypharmacy that we have decided to call “extreme poly-
pharmacy.”4,5 This category deserves special attention because there
are many consequences that can be derived from polypharmacy; it
has been observed that polypharmacy raises the risk of adverse reac-
tions (up to 82% for those patients who receive seven or more medi-
cations vs 13% in those who receive only two), the potential for
interactions, a lack of adherence to treatment and decreased func-
tional status in elderly patients.6
Extreme polypharmacy is more common in adults over 65 years
old who suffer multiple chronic noncommunicable conditions such as
arterial hypertension, diabetes mellitus, chronic obstructive pulmonary
disease, dyslipidemia, hypothyroidism, rheumatological diseases, and
other painful disorders; however, extreme polypharmacy is not exclu-
sive to this age group.1 Minors with severe and refractory epilepsy or
with cerebral palsy can also receive large amounts of medications. In all
cases, extreme polypharmacy is aggravated by therapeutic duplications
(more than one antiulcer, antidepressant, or hypnotic medication,
among others) from the care provided by multiple physicians in differ-
ent specialties who do not adjust their medications according to those
already prescribed by others. This leads to a greater number of possible
drug-drug interactions and an increased risk of adverse events, which
may go unnoticed by all of the prescribers.4 In addition, the costs of
care become very expensive (average: U.S. $272.5 per month, range
U.S. $34.9-3840.2 per month), which impacts health systems and
deserves special care from physicians and decision makers.
Because the majority of patients with extreme polypharmacy
have multiple morbidities, it is necessary to consider the clinical con-
text of each and the real medication needs; some patients may require
all of the prescriptions, which would be considered adequate poly-
pharmacy.7 However, all potentially inappropriate prescriptions that
may eventually worsen the quality of life of older adults or bring
adverse outcomes should be taken into account.8 Additionally, physi-
cians need to identify cases in which a prescription cascade has been
Pharmacoepidemiol Drug Saf. 2020;1–2. wileyonlinelibrary.com/journal/pds
presented from using medications for new conditions that may have
appeared as a result of adverse effects of other drugs that the patient
is receiving.9
We believe that extreme polypharmacy worsens the health condi-
tions of patients, makes attention more expensive, and undermines
the resources of health systems, so it deserves recognition as a cur-
rent situation of clinical and economic relevance. If we take into
account that the world population is aging and every day there are
more seniors who will have multiple diseases, then in the near future,
there will be a higher number of patients with extreme polypharmacy,
which will merit interventions that avoid an inadequate prescription
of medications, provide continuing education to physicians to reduce
this practice, and implement the use of clinically directed institutional
deprescription programs that limit the prolonged use of all unneces-
sary or inappropriate drugs for these patients.10 However, a simpler
way to reduce extreme polypharmacy may be to provide tools to phy-
sicians, pharmacists, and even the experts who develop clinical prac-
tice guidelines to prevent overprescription with appropriate
recommendations on the use of drugs. In the event that the health
system does not consider the family doctor as the axis of care, incor-
poration of the family doctor into the health team can reduce the like-
lihood of inappropriate polypharmacy. New research is required on
the epidemiological characteristics of patients with extreme poly-
pharmacy, as well as their risk factors, outcomes, and prevention
strategies.
CONFLIC T OF INT ER E ST
The authors declare no potential conflict of interest.
Jorge E. Machado-Alba1
Manuel E. Machado-Duque1,2
Andrés Gaviria-Mendoza1,2
1
Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia,
Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
2
Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
Correspondence
Jorge E. Machado-Alba, Grupo de Investigación en
Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica
de Pereira-Audifarma S.A., Calle 105 No. 14-140, Pereira, Colombia.
Email: machado@utp.edu.co
OR CID
Jorge E. Machado-Alba https://orcid.org/0000-0002-8455-0936
© 2020 John Wiley & Sons Ltd 1
2 LETTER TO THE EDITOR
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