Tuesday, February 2, 2010

Psychiatric Polypharmacy

Polypharmacy describes the tendency for an individual to be on more than one medication at a time. Historically it should be remembered that people didn't live as long and people with serious illness didn't live long enough to develop other illnesses. Poly pharmacy to a very large extent reflects the successes of modern medicine especially in keeping the ill alive and functional.

As an example the diabetic would come to the doctor and obtain insulin at best only to die young as a complication of the early inexperienced use of insulin and the early insulins. Today's diabetic can look forward to a long life where the natural complications of the disease of diabetes will result in them not surprisingly having medication to treat the vascular effects of diabetes on the heart and kidneys and eyes. They will however live relatively normal lives without debilitating symptons yet take several medications in addition to their insulin in their later years.

In addition to this one of the principal reasons for polypharmacy is the increased specificity of medication. In the past the pharmacy produced a 'brew' of medications with several drugs combined into one pill or 'potion'. This 'fixed" "one size fits all" approach was noted to be associated with the most side effects and decreased longevity. Tylenol #3 represents an example of the old approach with a combination of Acetominophen and Codeine continuing to have greater popularity than just codeine alone. In over the counter medications the tendency for a 'whole bunch ' of medications to be mixed in one is still common and people should carefully read ALL the medications that they're getting in 'one' ointment. These 'one pill', 'one ointment' , one brew are all as much polypharmacy if not more than the 2 or 3 or more 'specific' single treatments.

In psychiatry the 'one shoe fits all' 'single' pill with 3 or 4 in one has long gone by the wayside as specific individual medications have replaced those 'snake oil' approaches mostly because the combination of 'single' medications allows for greater potency without few side effects.

In Depression in psychiatry it is common to be treated with an antidepressant and a sleeping medication because not only do sleep disorders and mood disorders go hand in hand but sometimes the antidepressant can cause sleep disruption. Most people with depression have anxiety and the antidepressants anti anxiety benefits take weeks to a month to 'kick in' whereas a minor tranquillizer for anxiety can be beneficial immediately though has increasing risks in the long term. Right there a patient is on 3 medications and this is for a relatively uncomplicated major depression.

In contrast bipolar illnesses are commonly treated with a combination of mood stabilizer, an anti mania or anti depressive medication depending on the state of the patient with bipolar is in, a sleep medication and commonly atypical major tranquillizer.

The key feature is that the combination of medications can be used to augment each other. Caffeine and ASA (acetylsalicyclic acid) has long been included in over the counter pain medications simply because the cafeine 'augments' ASA action. This combination can allow less asa with it's tendency to reduce blood clotting and cause upset stomach because it enhances the efficacy of the pain relieving property of the medication.

Similiarly the various psychiatry medications properly used 'augment' each other and allow for lower dosing with less side effects overall. A classic combination used in this type of thinking is seen with antidepressants where buproprion or wellbutrin an activating energising antidepressant with cognitive attentional benefits is taken in the morning and an SSRI, such as medication, such as Trazadone, with greater antidepressant and antianxiety benefits as well as sleep inducing properties is taken at night. Here the combined overall dose of the medication would be equivalent to the antidepressant dosage of either one alone if not used in combination however together they have much greater benefits and the side effects of each, being different, ie effective different organ systems, is lesser overall.

Unfortunately when patients look up "side effects" on the internet the 'dosage" at which the side effects were seen is usually not available. Dr. Philip O. Anderson, Professor of Pharmacy and Director of Drug Information, University of California, San Diego and San Francisco in his extraordinary Handbook of Clinical Drug Data which is due for a new edition tabulates not the 'medical disclaimer" side effect information which the pharmaceutical companies give out for legal purposes and appears the principal basis of most internet sources but rather Dr. Anderson documents the much fewer side effects of the medications as used properly by clinicians in the teaching hospitals of California. Further, when clinical polypharmacy is practiced the dosage of any of the medications is most commonly far less than the dosage that the medication was shown to have side effects at in the CPS or compendium of pharmaceuticals and specialites ,the so called 'drug company' book.

The prime example for this in psychiatry is seen with the mood stabilizers. Valium or diazepam is a common seizure disorder medication that was found early to have anti anxiety properties at a lower dosage. Now we know a whole range of seizure medications have mood stabilizing and anti anxiety, or augmentation potential. An example is gabapentin. This very interesting seizure medication is used at 6000 mg by neurologists but was also found to be beneficial in preventing migraines at under a 1000 mg. It's also the 'treatment of choice' for 'restless leg syndrome' and is used there in the 1000 mg range and it's benefit in sleep disorders and pain treatment are seen at as low dosage as 100 mg. It's further been found to have physical anti anxiety benefits like valium without the psychological anti anxiety effects in dosages usually 100 three or four times aday to 300 mg three to four times a day.

What is significant here is that the 'side effects' listed are seen in the highest dosage whereas in these lower dosage they are rare. The same goes with Aspirin which is now used as a baby aspirin to prevent recurrent heart attacks but was used at high dosage for arthritis 12 or more aspirin a day. At the higher dosage there are many side effects including deafness and uncontrollable bleeding. I encourage people to read these common medications to put the other medication use in perspective and understand that a medication may be extremely safe taken as directed but appear on the internet or in books to have a whole lot of side effects.

Clinically in psychiatry poly pharmacy is indeed safer in many cases as individual symptons are targetted and the combinations of medications are used to augment each other and ensure that the least side effects occur with the greatest potency. The concern about mis reading and mis interpretting the information available on medications is that there is a tendency to psychologically develop a lot of symptons if we worry they're going to happen. A variety of autonomic nervous reactions which are triggered by fear cause people to reject perfectly good and safe medications because they have nausea or tingling sensations or feelings of panic because having read the side effects of medications without clarification, they think they're going to have some dire and rare complication of a medication that is being given for its life saving or life enhancing benefits.

Admittedly the principle negative of side effect of polypharmacy is cost. More pills, more money. As a result once a person's condition is 'stabilized' it's commonly possible for the clinician to reduce the overall medications and also to look at less expensive 'generic' medications to help reduce costs. However, while people will say that a Gucci bag knock off is the same as a Gucci bag many patients, not the majority by any means, note that Prozac for instance is more effective than Fluoxetine. It's a clinical fact. Still for many the 'knock off' generics at much less cost work as well and often if cost is a factor and the initial emergency or crisis is address long term solutions where cost can be frightening can be addressed with cheaper alternative. As an example a patient treated for depression and suicidal ideation with Cipralex or Cymbalta the newer and naturally more expensive medications, combined with Zopiclone sleeping medication, when well again may need to be on the medication for a year more for prevention given the risk of recurrence related to the near death experience. This year of medication is being used as prevention and as a cost saving alternative the very low dose tricyclic medication amitriptylline might be used as an alternative and the patient might prefer to tolerate the side effect of dry mouth and constipation for a much cheaper alternative. In an acute situation I would today want to use Cipralex but as a clinician would see benefit in longer term prevention use utilizing a tricyclic antidepressant because patient compliance might be increased if the cost isn't so painful.

These a just some of the considerations that need to be reflected on when faced with patients being on several medications. Last year I had several patients hospitalized because some well meaning but ignorant person told them "You're on too many medications". My schizophrenic patients stopped all her medication, the three psychiatric medications, the one heart medication, and the thyroid medication. 6 weeks of hospitalization before she was discharged again on six medications.

1 comment:

Steve Berke said...

I enjoyed reading this article. PLease continue publishing helpful topics like this. Regards, from beddingstock