Multimedia

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Under multi-medication , polypharmacy or polypharmacy concomitant use or regulation of different is drug understood against several diseases. Multimedication is understood to mean the simultaneous use of several drugs or the simultaneous and continuous administration of five or more active ingredients, although this is not defined uniformly. According to a systematic review of the scientific literature, no fewer than 138 definitions for polypharmacy were found in the 110 publications evaluated. In 2017, the World Health Organization (WHO) defined polypharmacy as “the simultaneous and regular use of four or more over-the-counter, prescription or traditional medicines”.

frequency

Multimedia is a very common phenomenon, but it is only recently that more attention has been paid to it. Even if multimedia can be observed particularly often in older age, due to the co- or multimorbidity that is often present , problematic multimedia is often also present in psychiatric clinical pictures and even in children and adolescents.

The frequency of multimedia is increasing worldwide, even in emerging and developing countries. This is due on the one hand to increasing life expectancy and on the other hand to the increasing number of people who have access to medicines. In industrialized countries, the prevalence of multimedia is between 25 and 80%, depending on the definition used, the region examined and the health sector. According to a population-based survey from 2008–11, the rate of multimedia (definition ≥5 drugs) in Germany was 13.6% for adult women and 9.9% for men. 71.8% of the preparations taken were prescribed by the doctor, 27.7% came through self-medication . Older people in nursing homes represent a particular problem group. According to a cross-sectional survey of Austrian nursing homes from 2013, the average number of drugs taken by residents was 9, with 72.4% having at least one potentially inadequate drug (PIM) .

Problems

Multimedication is associated with a variety of drug-related problems. These include adverse events such as falls or bleeding, avoidable examinations and treatments, adherence problems, unplanned hospital admissions and deaths. There appears to be a linear relationship between the number of drugs taken and the frequency of drug-related problems. Paradoxically, multimedia is often associated with under-treatment, i.e. withholding important therapies.

Although numerous tools for optimizing pharmacotherapy with the aim of improving drug therapy safety are available today, it is still usually not possible to discontinue medication that is no longer required in multimorbid patients . A systematic review from 2017, which included 25 studies with sometimes very complex interventions in multimedia, came to the conclusion that, despite a structured approach, usually only a minimal reduction in the number of drugs prescribed can be achieved (from an average of 7.4 to 7.2 permanent prescriptions). In addition, there was no measurable effect on clinically relevant endpoints such as hospital admissions or mortality. Possible reasons for this disappointing result could be that the interventions were mainly limited in time, e.g. B. in the context of hospital treatment, often based solely on the files and by specialists (clinical pharmacists, geriatrists, internists) to whom the patients and their living conditions were too unknown. Further explanations could be that the patients were insufficiently informed and insufficiently involved in the measures taken. The medicinal product letter criticizes the fact that none of the studies aimed at reducing multimedia use included sham interventions. This aspect is particularly important, since unwanted reactions can be expected with every change in medication , for example through pharmacologically based withdrawal symptoms and / or psychological uncertainty in the patient. Withdrawal from drugs could trigger fears in patients or their relatives that they would be given up as a hopeless case or for economic reasons.

Doctors and patients obviously find it difficult to stop taking medication - even when there is enough evidence of a benefit. This has been shown to apply to antihypertensive drugs and antidiabetic drugs , but also to proton pump inhibitors and many psychotropic drugs . With many drugs there is an added barrier that it can be difficult to stop, e.g. B. because of withdrawal symptoms , and a monitored "tapering off" required. Therefore, special “deprescribing” guidelines are increasingly being developed. The authors of medical guidelines are also responsible. These should not only make recommendations for intensification, but also for de-intensification of medical measures.

In principle, a trusting cooperation between the patient and the treating physician is essential in order to avoid possible problems caused by multimedia. The family doctor's practice is probably the key point for medication management. General practitioners prescribe> 85% of prescription drugs and have the closest and most continuous contact with patients. However, there are a number of uncertainties for general practitioners. The first prescription of medication is often done without consulting you and by specialists and hospital doctors who do not work as general practitioners . The discontinuation of such an order by the family doctor can lead to a crisis of confidence in the patient or their relatives. In addition, there are often legal uncertainties that can stand in the way of discontinuing a specialist prescription.

The optimization of prescribing practice in the field of polypharmacy is one of the aspects within the implementation of the UN Sustainable Development Goals in order to reduce the need for pharmaceuticals and thus environmental pollution in addition to health promotion , also against the background of the likely increase in pharmaceutical consumption as the population ages.

history

The term 'polypharmacy' first appeared in English-language specialist literature around the mid-1950s. This was understood to mean “pages of medical formulations with complex mixtures of active ingredients using corrective agents, adjuvants and vehicles”. William Osler used the term in the early 20th century. As he wrote, “ The struggle against polypharmacy, or the use of a great number of medicines (which we know little about but which we put in bodies without understanding how they work) has not yet been completed. "

See also

Individual evidence

  1. ↑ N. Masnoon, S. Shakib, L. Kalisch-Ellett, G. Caughey: What is polypharmacy? a systematic review of definitions . In: BMC Geriatr . tape 17 , 2017, p. 230-239 , PMID 29017448 .
  2. ^ World Health Organization (WHO): Medication without Harm. (PDF) WHO, 2017, accessed on April 11, 2018 .
  3. ↑ H. Kersten, S. Ruths, TB Wyller: Pharmacotherapy in nursing homes. In: Tidsskr Nor Laegeforen. Volume 129, No. 17, Sep 10, 2009, pp. 1732-1735. PMID 19756052 .
  4. ↑ K. Johnell, J. Fastbom: Multi-dose drug dispensing and inappropriate drug use: A nationwide register-based study of over 700,000 elderly. In: Scand J Prim Health Care. Volume 26, No. 2, 2008, pp. 86-91. PMID 18570006 .
  5. ^ N. Siegmund-Schultze: Polypharmacotherapy in old age: Less medication is often more. In: Deutsches Ärzteblatt. Volume 109, 2012, pp. 418-420.
  6. ↑ HD Basler, S. Hesselbart, G. Kaluza, M. Schuler, W. Sohn, Th. Nikolaus: Comorbidity, multimedia and well-being in older patients with chronic pain. In: The pain. Vol. 17, No. 4, August 2003, pp. 252-260 doi: 10.1007 / s00482-003-0231-0
  7. ^ B. Zhu, H. Ascher-Svanum, DE Faries, CU Correll, JM Kane: Cost of antipsychotic polypharmacy in the treatment of schizophrenia. In: BMC Psychiatry. Volume 8, Apr 4, 2008, p. 19. PMID 18394168 .
  8. ^ Y. Du, H. Knopf: Self-medication among children and adolescents in Germany: results of the National Health Survey for Children and Adolescents (KiGGS). In: Br J Clin Pharmacol . Volume 68, No. 4, October 2009, pp. 599-608. PMID 19843063 .
  9. ↑ GD Äthoíop, MY Tadele, AA Bontu: Polypharmacy and the contributing factors among elderly patients in shashemene referral hospital, West Arsi, Oromia region, Ethiopia . In: J Bioanal Biomed . tape 9 , no. 6 , 2017, p. 277–282 (English, omicsonline.org [accessed April 5, 2018]).
  10. ↑ H. Knopf, D. Grams: Medicinal application by adults in Germany. Results of the study on adult health in Germany (DEGS1) . In: Federal Health Gazette . tape 56 , 2013, p. 868-877 , PMID 23703508 .
  11. ^ R. Alzner, U. Bauer, S. Pitzer, MM Schreier, J. Osterbrink, B. Iglseder: Polypharmacy, potentially inappropriate medication and cognitive status in austrian nursing home residents: results from the OSiA study . In: Wien Med Wochenschr . tape 166 , no. 5-6 , 2016, pp. 161-165 , PMID 26847440 .
  12. ^ A b D. Moßhammer, H. Haumann, K. Mörike, S. Joos: Polypharmacy-an upward trend with unpredictable effects . In: Dtsch Arztebl Int . tape 113 , no. 38 , 2016, p. 627-633 , PMID 27743469 .
  13. ↑ T. Johansson, ME Abuzahra, S. Keller, E. Mann, B. Faller, C. Sommerauer, J. Höck, C. Löffler, A. Köchling, J. Schuler, M. Flamm, A. Sönnichsen: Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis . In: Br J Clin Pharmacol . tape 82 , no. 2 , 2016, p. 532-548 , PMID 27059768 .
  14. ↑ a b Multimedication: Why is it often so difficult to reduce medication? In: The medicament letter. WD Ludwig, J. Schuler, 2018, accessed April 5, 2018 .
  15. ↑ Deprescribing Network, Bruyère Research Institute: Deprescribing Guidelines. Retrieved April 5, 2018 .
  16. ↑ T. Hillenbrand et. al: Improvement of the water quality through reduced inputs of trace substances . In: WL Filho (Ed.): Current approaches to the implementation of the UN Sustainable Development Goals , Springer Verlag, 2019, p. 306 ( limited preview in the Google book search).
  17. ↑ Medicines in the Environment , Federal Environment Agency , October 11, 2019.
  18. ↑ WB Bean: Vita Mania, polypharmacy, and witchcraft . In: JAMA Arch Intern Med . tape 96 , 1955, pp. 137-141 , PMID 14397872 .
  19. ^ College of Physicians - American Society of Internal Medicine: The Quotable Osler . Ed .: Mark E. Silverman, TJ Murray, Charles S. Bryan. ACP Press, 2008, ISBN 1-934465-72-0 .
  20. ↑ https://books.google.de/books?hl=de&id=lBLWCQAAQBAJ&dq=Aequanimitas&q=battle+against+polypharmacy