This is Part 2 of a four-part Patient Case Quiz.
Click to access: Part 1 | Part 2 | Part 3 | Part 4
Mr. C is an 85-year-old male referred in 2017 for a second opinion with cardiology for episodic "whiteouts."
The focus on Part 2 of this series is polypharmacy:
Mr. C's cumulative number of prescribed medications are: 12
Mr. C's number of prescribed cardiovascular medications are: 7
For further review of individual medications and original case: [Original patient case scenario here].
Case Question #2: Can Mr. C be defined as having polypharmacy and can decreasing medication burden (deprescribing) be considered on an ethical basis?
The correct answer is: 5. Yes (this is polypharmacy) and Yes (decreasing medication burden or deprescribing can be considered on an ethical basis).
The definition of polypharmacy is ≥5 medications. Hyper-polypharmacy is defined as ≥10 medications.1,2
Adverse Drug Events (ADE): increases by 7-10% with each medication
Falls: if ≥4 medications, increases by 18%
Delirium: if ≥6 medications 2 times more; if ≥ 10 medications 2.5 times more
Cognitive decline: mixed data
Mortality: if 6-9 medications, increases by 59%
Furthermore, a term recently introduced by the Lown Institute is medication overload.3 Medication overload was defined as "the use of multiple medications for which the harm to the patient outweighs the benefit." Of note, medication overload is associated with ADE and other negative clinical outcomes.
Yes, deprescribing is concordant with ethical principles when serving patient-centered interests (beneficence, nonmalfeasance, autonomy, and justice).2
Approach to Deprescribing: The primary indication to deprescribe in Mr. C's case is the abolishment or reduction of his disabling symptoms that he has had for many years. His "whiteouts" were thought to be a result of his underlying heart failure, low blood pressure and adverse medication effects prescribed for heart failure.
Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in older adults with cardiovascular disease. J Am Coll Cardiol 2019;73:2584-95.
Gorodeski EZ, Goyal P, Hummel SL, et al. Domain management approach to heart failure in the geriatric patient: present and future. J Am Coll Cardiol 2018;71:1921-36.