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Polypharmacy - A Case Report and New Protocol for Management
A New Protocol for the Management of Polypharmacy
Polypharmacy is associated with adverse complications and is frequently iatrogenic. The precise number of drugs the patient is taking appears to be less important than the clinician's ability to relate the use of each drug to the patient's medical, social, and economic circumstances.[18] It is imperative that physicians recognize and manage polypharmacy aggressively.
It is with the above in mind that I have developed the SAIL protocol for appropriate prescribing (Table 3). This mnemonic is intended to help physicians minimize polypharmacy in their clinical practice. Simple drug regimens can usually be achieved by prescribing drugs that can be taken once daily[18] and by changing to a single combination pill when adding a second drug.[6] Although the direct cost of such a regimen might be higher in the short-term, the potential costs of long-term polypharmacy must be weighed when considering the economics of a particular regimen.[25] The physician must also possess a thorough knowledge of the adverse effects of all drugs the patient is taking,[6,8,26] including the side effects of a drug as well as its interactions with other drugs. The indication for each drug the patient is taking must be clearly understood.[18,26] Each drug should have a well-defined therapeutic goal and must achieve the desired goal or be eliminated from the patient's medication list.[18] Finally, the physician and the patient both should have an accurate and current list of the medications.[18,26-28] This list must include all prescriptions, over-the-counter medications, as-needed medications, and herbs and other alternative medicines.
Although the SAIL protocol has not yet been tested in clinical practice, its application in this particular case shows how it can be effective in managing polypharmacy. The patient's regimen was simplified by structuring her drug regimen to include only medicines that are taken once daily. Additionally, prescribing a combination drug amlodipine/benzapril rather than a calcium channel blocker plus an ACE inhibitor decreases the total number of pills the patient has to take. Drugs with adverse effects, such as clonidine, and drugs with potential adverse effects, such as digoxin and allopurinol, were discontinued. Several drugs that had no indication, such as digoxin, allopurinol, and isosorbide dinitrate, were discontinued.
Finally, prescribing errors occurred because clinicians had not maintained an accurate, up-to-date list of this patient's medications, as evidenced by the patient taking two ACE inhibitors simultaneously. Reducing the list of medicines to three pills a day has made her drug regimen more manageable both for the patient and her physicians. In this patient, the SAIL protocol managed polypharmacy effectively and reduced its complications, morbidity, and cost.