The Polypharmacy Predicament

Published on July 06, 2016 by Dr. NavNirat Nibber

Navigating your way through the complicated world of healthcare can be tricky. It can be difficult to eat right, fitting in time to exercise, maintaining good posture, making sure your oral hygiene routine is up to par, and on and on. Everything is complicated even further by when you try to medications with supplement schedules. The prescription and concurrent use of multiple medications has increased significantly over the past 15-20 years. It is reported that claims to provincial drug benefit programs in individuals over 65 years old increased by 214% from 1997-2006 in Ontario. That being said polypharmacy is no longer a problem isolated to the elderly. It is becoming more and more common to see individuals prescribed multiple, potentially competing pharmaceutical, drugs. Further, complicated by the fact that many well intentioned individuals may be self prescribing a gamut of supplements.

Each drug has its own set of adverse reactions which may lead to physicians prescribing more drugs to manage these side effects. This can lead to a slippery slope of over prescription, referred to as a prescribing cascade. Adverse effects from medications can be exacerbated by the improper prescription or misuse of medications known as potentially inappropriate medication (PIM). For example, when individuals continue with medications when it is no longer indicated. Medications can also cause some malabsorption or nutrient deficiencies, with associated adverse symptoms. This may occur immediately or over the course of drug administration, or can be the result of abrupt withdrawal of the drug. Below is a table that highlights some of the most common drug associated deficiencies and their health consequences.

Drug or Drug Class Depleted Nutrients Deficiency symptoms
Antibiotics such as penicillin
  • Calcium
  • Magnesium
  • Vitamin K
  • Alters gut flora (ie.good bacteria)
With altered gut bacteria individuals may have digestive upset, malabsorption and altered immunity.
Statins
  • Coenzyme Q10
Has been directly related to statin induced muscle pain and weakness.
Hydrochlorothiazide
  • Potassium
  • Coenzyme Q10
  • Magnesium
 
These thiazide diuretics used for blood pressure reduction have been shown to cause sexual dysfunction, hypokalemia, and muscle weakness.
Ulcer medications such as Zantac
  • Vitamin B12
  • Iron
  • Folic acid
  • Protein
  • Zinc
Altered stomach acid levels can lead to pernicious anemia due to inability to absorb vitamin B12 which can manifest as neurologic dysfunction, numbness, and fatigue.
Syntheroid
  • Calcium
With altered calcium levels individuals bone health may be impacted. Are at higher risk of developing osteopenia or osteoporosis.
Oral contraceptive pills
  • Folic acid
  • B vitamins: B1, B2, B3, B6, B12
  • Vitamin C
  • Zinc
Depleted B vitamins can result in poor neurotransmitter synthesis affecting mood and cognition.
NSAIDs
  • Folic acid
  • Iron
  • These commonly prescribed pain medications can also lead to ulcer formation which inhibits nutrient absorption
Cognitive impairment, fatigue, and reduced folic acid can lead to neural tube defects in pregnancy.
Oral Hypoglycemics eg. Metformin
  • Folic acid
  • Vitamin B12
  • Coenzyme Q10
With a reduction in folic acid and B12, homocysteine levels increase which increases risk for heart disease.

So what can patients and physicians do to mitigate the damage?

  1. Focus on prevention: As a naturopath, I am a huge proponent of optimizing health thereby reducing the number of risk factors for chronic diseases. Prevention is the most sustainable option as it reduces the need for the prescription cascade.
  2. Education: Luckily the majority of the most commonly prescribed pharmaceutical drugs are well researched. Mechanisms of action and side effects have been well documented and drug monographs are accessible. It is important for individuals to work with allied health professionals to create drug and supplement regimes that are appropriately prescribed but also appropriately administered. Patients should have a clear understanding of why they are being prescribed  a particular medication. Patients should be briefed on what they can expect side effects to be and when they may appear. How they should take the medication, ie with or without certain foods, or time of day. Finally patients should be clear on how long they should be taking these medications. Often individuals stay on medication long after they should simply out of habit. This is true for supplement regimes as well, which are often thought of as benign and completely safe. However, inappropriate supplement use can have significant repercussions on your health. Depending on how you are taking supplements you may also be missing out on their value, for example calcium can block the absorption of iron, while vitamin C improves absorption. These details represent the difference between health benefits, and very expensive urine.
  3. Correct Deficiencies: While ever individual may need to alter their diet to comply with their medication they may also be able to supplement some of the nutrients that are depleted. AOR has developed a formula called Pro Cogni-Co-factors this formula includes magnesium, vitamin B6, vitamin B3, vitamin B12, folate ( in its active form) and zinc. As you can see in the table these nutrients are often depleted by common drugs.  Pro Cogni Co-factors specifically addresses the most commonly depleted nutrients while still ensuring safety and efficacy of the drugs that deplete them. It is only available through your health care provider to ensure safety with medications.
  4. Monitor: physicians have a responsibility to regularly monitor a patient's response to any prescription or recommendations provided to ensure these treatments are appropriate, efficacious, and safe for the individual. Monitoring criteria such as Beers and STOPP criteria are constantly being evaluated and updated to ensure the highest standards are available.

Prescription drugs can be essential for an individual's well being, the side effects can be both positive or negative. The answer may not be in eliminating the drugs completely, but in education and prevention. Individuals must work with their healthcare providers to understand the risks versus the benefits when determining if the prescription is appropriate for them. With this in mind perhaps we can curtail this endless “prescription cascade” and make the healthcare journey a little simpler.

Image by Gina Sanders via Adobe Stock

Let us know what you think? Have you had an adverse reaction to a medication? How did you and your healthcare provider react?

References
Anthierens S, Tansens A, Petrovic M, et al. Qualitative insights into general practitioners’ views on polypharmacy. BMC Family Practice 2010;11:65.

Bajcar JM, Wang L, Moineddin R, et al. From pharmaco-therapy to pharmaco-prevention: trends in prescribing to older adults in Ontario, Canada, 1997-2006. BMC Family Practice 2010;11:75-80.

Bottiglieri T, M Laundy, R Crellin, et al. “Homocysteine, folate, methylation, and monoamine metabolism in depression.” Journal of Neurology, Neurosurgery & Psychiatry Mar 2001; 70(3): 419.

Bottiglieri T. “Folate, vitamin B12 and neuropsychiatric disorders.” Nutrition Review Dec 1996; 54(12): 382-390.

Canadian Institute for Health Information. Chapter 3: Primary health care and prescription drugs – key components to keeping seniors healthy. In: Health Care in Canada, 2011: a focus on seniors and aging. Ottawa, ON: Canadian Institute for Health Information; December 2011. https://secure.cihi.ca/free_pr... seniors_report_en.pdf (accessed January 17, 2013).

Clayton JA, Rodgers S, Blakey J. Thiazide diuretic prescription and electrolyte abnormalities in primary care. Br J Clin Pharmacol 2006 Jan;61:87-95.