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The basic concept of the use of multiple medicines (polypharmacy) is quite simple: the prescription of more medications than are clinically appropriate.The incidence of drug-drug interactions (DDIs) increases with the number of drugs used, with prevalence and incidence of clinically observable DDIs is between 5- 25% of patients on pharmacological treatment. DDIs also contribute substantially to differences in drug response. DDIs are the source of adverse drug reactions (ADRs). 10 % of ADRs are due to DDIs. The use of 5 drugs used chronically is a figure from which there is an independent relationship with the inappropriate use of medicines: the frequency of ADRs is 6% when a patient takes two medications, 50% when he takes five, and almost 100% when he takes eight or more medications. In this scenario, it could be hypothesized that the presence of polypharmacy is an indicator of malpractice and poor quality of family medicine service. Thus, some techniques could be suggested for judiciously avoid polypharmacy in family medicine: 1) Use drugs only in authorized indications; 2) Use only indicated drug combinations; 3) Avoid starting treatment with two drugs from the same drug group; 4) avoid using the last commercialized drug, of which there is almost no experience; 5) Avoid using higher doses than indicated at the beginning of prescription; 6) Avoid using a drug longer than indicated, and 7) Not treating ADRs with other drugs.
The concept of the use of multiple medicines (polypharmacy) or “polymedicated patient” varies depending on the source consulted, but the basic defi nition is quite simple: the prescription of more medications than are clinically appropriate [1, 2].
Thus, two possible situations could be distinguished according to the intervention: appropriate polypharmacy (when the patient takes many drugs, but all of them have clinical indication; here, it would be possible not to reduce, but to improve the therapeutic adequacy), and the inadequate polypharmacy (here, it would be to reduce the maximum possible number of inappropriate drugs) .
However, in general polypharmacy has been defi ned in quantitative terms, although there seems to be no consensus on where to establish the limit from which we would be talking about polypharmacy, and in any case they are almost always arbitrary criteria. For some authors, taking only two medications would be polypharmacy, and for others it would be the daily consumption of four, fi ve or even eight drugs. The most widespread number seems to be that of 5 drugs used chronically, a fi gure from which, there is an independent relationship with the inappropriate use of medicines. It should be noted that the frequency of adverse drugs reactions (ADR) is 6% when a patient takes two medications, 50% when he takes fi ve and almost 100% when he takes eight or more medications [4, 5].
On the other hand, the incidence of DDI increases with the number of drugs used and with age. 10 % of ADRs are due to DDIs. Different authors report similar fi gures: the 5% -10% of patients receiving pharmacological treatment has IDD. The prevalence and incidence of clinically observable DDIs is between 5-10% and up to 25% of patients on pharmacological treatment, and potential DDIs is at least three to fi ve times higher (from 15% to 50%), and even a nearby figure to 100% in geriatric patients on pharmacological treatment. Drug-drug interactions can also contribute substantially to differences in drug response. Drug-induced inhibition of drug metabolising enzymes is usually competitive and causes an increased exposure of the drug whose metabolism is inhibited. This usually results in a higher incidence of ADRs and an increased severity. Conversely enzyme induction increases the metabolic capacity thereby reducing the exposure of a drug with sometimes loss of drug effects (nonresponse) [6, 7, 8].
It is true that polypharmacy is a marker of multimorbidity, but does the presence of this fact totally justify polypharmacy? What factors besides multimorbidity influence polypharmacy? To answer, pharmacological agents and polypharmacy must be considered in a holistic way .
In this scenario, some hypotheses could be issued to check: 1) the polypharmacy does not depend exclusively on the multimorbidity; 2) the polypharmacy does not depend on the size of the general practitioner (GP) patients list (large lists may have little polypharmacy and small lists may have a lot of polypharmacy); 3) there is a great variability among physicians of the prevalence of polypharmacy (all this means that the predictable prevalence of polypharmacy could is between 10% and 20%, although there is a great variability per GP: from 4-5% until 18-30% according to GP), 4) the main cause of polypharmacy (of excessive use of drugs) is the professional. Taking into account the great variability in the prevalence of polypharmacy between practices of general medicine within the same geographical area and subject to the same health policies and budgets, and which does not appear to be justified by differences in the characteristics of the patient list attended (age, sex, social level, morbidity), it is necessary to think that it is the medical action that is responsible (10); 5) regardless of the development of protocols to desprescription, should be working on the training of the doctor and on the possible causes that influence their poly-prescriptive behavior (such as lack of time, excess demand, marketing of the pharmaceutical industry, leader effect from the hospital doctors, etc.) to favour a kind of reflective GPs, who feel capable of maintaining their opinions based on evidence, and they are critics about possible external pressures.
In this scenario, it could be hypothesized that the presence of polypharmacy is an indicator of malpractice and poor quality of the general medical service, which should be used to improve the clinical care of patients , although the confounding effects of health policies and health budgets, must be taken into account. In addition, stratification of polypharmacy, such as by geography, age, primary indication of disease, etc., would be useful for validity of the hypothesis.
In this way, some techniques could be suggested to judiciously avoid polypharmacy: use drugs only in authorized indications (for example, avoid antipsychotics or topiramate for adaptive disorders); use only indicated drug combinations; avoid starting treatment with two drugs from the same drug group (for example, do not start treatment of depression with two antidepressants); avoid using the last commercialized drug, of which there is almost no experience; avoid using the higher doses than indicated at the beginning of prescription (for example, do not start with paroxetine 60 mg daily); avoid using a drug longer than indicated (for example, do not use benzodiazepines chronically); and not treating ADRs with other drugs (for example, for dyspnea by ticagrelor, not prescribing opioids or furosemide, but withdraw the causative drug) .
Sometimes, in medicine, we should learn from the work of historians: they accumulate facts about which they theorize later. The facts not only follow one another, but also all orientate in a visible direction; that is, they set a pattern: a series of facts originates an orderly development from the cause to the inevitable results. The investigator must not only record the facts, but explain the causes of the events and show a certain order that transcends mere temporal succession. Thus, polypharmacy originates a series of facts that lead to medical malpractice, and this is a cumulative process. However, this described development is not a unique process and not subject only to external interventions; on the contrary, it is in our hands to use a series of techniques that can judiciously avoid polypharmacy in family medicine.