What is polypharmacy and why is it important?

Medication is by far the most common form of medical intervention for many acute and chronic conditions. Medication can be highly effective in preventing or slowing disease progression, with guidelines for single conditions recommending the use of a variety of evidence-based medicines. However, there is often a mismatch between prescribing guidelines for specific medical conditions and the range of clinical complexity found in individuals. For those with complex multiple conditions, frailty, a dominant condition (e.g. dementia) or approaching the end of their lives, the implementation of the sum of evidence-based recommendations may not be rational, may increase the risk of medicine-related harm and may not align with the individual’s preferences.

The term polypharmacy itself just means “many medications” and is defined to be present when a person takes two or more medicines. When polypharmacy is beneficial, it is considered ‘appropriate’. For example, treatment of left ventricular systolic dysfunction (heart failure) may include the use of several different classes of drugs.

Appropriate polypharmacy is present, when:

1. all medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the individual
2. therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future
3. medication has been optimised to minimise the risk of adverse drug reactions (ADRs) and,
4. the individual is motivated and able to take all medicines as intended.

Inappropriate polypharmacy is present, when one or more medicines are prescribed that are not or no longer needed, either because:

1. there is no evidence-based indication, the indication has expired, or the dose is unnecessarily high
2. one or more medicines fail to achieve the therapeutic objectives they are intended to achieve
3. one, or the combination of several medicines cause unacceptable ADRs, or put the individual at an unacceptably high risk of such ADRs, or
4. they are not willing or able to take one or more medicines as intended.

The appropriateness of polypharmacy should be considered at each initiation of new treatments for the individual, and when the person moves across different health care settings, that is, through transitions of care. The increased risk of harm is not always offset by increased benefits, and for many preventive medicines, such benefits may never be realised due to a limited life expectancy. The risk of harm is generally higher in older people with multimorbidity than in younger people due to pharmacokinetic factors, such as reduced ability to clear medication (e.g. kidney and/or liver impairment); pharmacodynamic factors such as increased vulnerability to medication-related harm (e.g. general frailty, drug–drug and drug–disease interactions); and medication burden.^14,15,16

There are five clear stages when appropriate polypharmacy requires consideration:

1. Prescribing (and risk assessment)
2. Medication review
3. Dispensing and administration
4. Communication and patient engagement
5. Medication reconciliation (at care transitions)

The majority of harm, 53% occurs at the ordering/ prescribing stage and 36% at the monitoring/ reporting stage, with 80% of the avoidable harm arising at the ordering/ prescribing stage.⁸ Although Polypharmacy Guidance: Appropriate Prescribing - Making medicines safe, effective and sustainable 2026-2029 concentrates on a holistic 7-Steps person-centred medication review, the principles, tools and recommendations can be used at any time, especially at the initiation of medication and when a person moves across the care transitions.

 

The 7-Steps medicine review process

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