Too Many Medications! The Case for Deprescribing

Here’s some advice on how to decrease your number of medications.

Wouldn’t it be great if your doctor started taking you off of medications instead of putting you on them? Recently, doctors have been making a push to move more towards less medications instead of more, especially in the elderly.  Medications are not without their problems including side effects, interactions with other medications and rising costs.  My patients know that I will try to avoid a medication at all cost and it is a last resort when non-medication alternatives have failed. If you are over 65, or have a parent or grandparent who is, this article is for you. If you are under 65 and on many medications, take heed as well.

Shortly after I finished my residency I worked in a community clinic.  My education had taught me to notice a problem, figure it out and find a solution.  I had also somewhere found (incorrectly so) that the solution was typically medication.  There was a patient who had come to me taking a few medications and had a new complaint each time he came in.  I properly diagnosed the problems and added a medication to treat the issue.  Before long he was on 10 different medications!  I realized my error and quickly paired down the list.  This taught me a valuable lesson that every complaint that walks in the door does not need a new medication. In fact, I now always look to make sure one of the person’s medications is not causing the problem.  Despite my efforts I still know of and treat many patients with more than 5 medications on board.

First, how did we get here?  Why are so many people, especially those over 65 on so many medications? A lot of it comes from recommendations from experts.  For example, if a person has diabetes there are recommendations to keep their diabetes under control (1 med), protect the kidneys and keep blood pressure under control (another med), and control heart attack risk (2 more meds: aspirin and a statin). This is assuming multiple meds are not needed to control the diabetes or blood pressure. Four meds from 1 disease process!  

Fractionation of care has also led to this.  People are often referred out to specialists for each of their problems: a cardiologist for their heart issues, pulmonologist for their lungs, etc.  Each of these doctors prescribes a medication to control the issue at hand without big regard for the other systems.  Before you know it, you’re on over 5 medications. It is the primary care provider’s job to view the big picture and make sure all of the medications are appropriate. Lastly, (and in my opinion, most importantly) it is easier to prescribe medication than to discuss making lifestyle changes.  Often we have only 15 minutes and adding on a medication takes much less time than having a conversation about proper diet and exercise or other non-medication ways of treating a problem. 

All medications have risks.  These risks increase when multiple medications are taken due to possible interactions.  Research shows us that as you increase the number of medications, the likelihood of interactions also increases.  Two medications have a 13% chance of interaction and this jumps to 38% with 5 medications. More than 7 medications has an 82% chance of interactions! This is why it is recommended to try to keep to less than 5 medications.  You can quickly check your medications and see if there are any interactions here. (Please note that not all interactions are clinically significant and any concerns should be discussed with your doctor). Medication interactions and side effects are especially true in the elderly.

This may be big news to you but as you get older, your body changes.  This is not only true for the outward appearance but your internal organs as well.  Medications are typically cleared through the liver or kidneys.  As you get older, the function of these organs declines which means that they are not able to clear medications as well.  A medication at the same dose when you were younger will have a larger effect when you are older because it is in your system longer.  A quick example: that 5 mg Valium you took when you were 40 now has dramatically increased risk of harming you at 65.  In fact there are many medications that are not even recommended after age 65 due to this reason.  A list of these can be found here.

Another concern for medications is costs for prescriptions are rising.  This is due to many reasons including changing health plans and new, non-generic medications.  Whenever possible I try to prescribe generic medication to decrease costs.  I also avoid any interactions with drug representatives so as not be swayed by their influence.  Personally, I do not have a stake in any pharmaceutical companies to avoid any conflicts of interest.  I rely on non-sponsored articles to get my information for prescribing so my prescriptions are the best and most cost effective for my patients.  Many doctors follow a similar code.

Lastly, every medication has side effects.  The best way to avoid this is to start low and go slow. If your doctor feels that you need a medication, you should know about its side effects.  When I prescribe I will usually give the most pertinent side effects that the patient should look out for and not an extensive list. At the pharmacy you can always obtain a comprehensive list of all the possible medications.

I want to make a quick disclaimer here.  Many medical problems need medications and they should be taken.  Please defer to your doctor’s judgement.  Here are some ways you can approach your doctor with any concerns. First, schedule a medication check up, a visit dedicated to reviewing your medications.  Prior to your appointment, run an interaction checker to see if there are any interactions and print this out for your appointment. Second bring a bag full of all your medications and supplements as well as any information on interaction or side effect concerns.  Third, present all of this information to your doctor.  Ask any questions you have to make sure you understand your medications and what they are for. Ask about the appropriateness of medications and any concerns of interactions or side effects. Work with your doctor to come to an agreement moving forward with your medications.

Hope this helps.  Let me now of your experiences in the comments below.

2 thoughts on “Too Many Medications! The Case for Deprescribing”

  1. I agree with you. Myself I got in the morning: Prednisone (Addison disease), 2 different kinds of meds for my epilepsy, 20 mg oxycodone depot (I have both psoriasis arthritis and rheumatoid arthritis), 1 allergy tablet and 15 mg cipralex (seratonin for my PTSD).

    I used to have 30 mg OxyContin but I don’t want it anymore after they gave me two doses extra by mistake on the hospital and I was on the way in to coma when they found me and they had to give me antidote and then there was a nurse who was sitting beside my bed all night long and did checks on me regularly during the night.

    So when I came home from the hospital I contacted my doctor and said that I wanted to get rid of the OxyContin. I takes it 4 times a day and we are working our way down. I now have 10 mg on every dose and as a replacement medicine I have Citodon. It’s a mixture of kodein and paracetamol. He offered me Tramadol but I said no thanks! Next week we are going down to 5 mg on every dose of OxyContin. I have a lot off pain but I think that much off it comes from the weather-change and the rest comes from my head…. withdrawn symptom I guess…

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