Steve Goldberg
In today’s healthcare system, we stand at a critical crossroads when it comes to medication management. For decades, the practice of polypharmacy — prescribing multiple drugs to treat various symptoms and conditions — has been the default approach, particularly for older adults and patients with chronic illnesses. However, this one-size-fits-all method is failing too many. The consequences of this scattershot approach are clear: a rising tide of adverse drug reactions, ineffective treatments, and overwhelming costs that burden both patients and the system.
To improve medication management, patients, providers, and pharmacists must work together and take advantage of prescription technology based on precision medicine, especially those that enable precise prescribing.
One such area of precision medicine is pharmacogenomics, which tailors treatments to the genetic makeup of each patient. For instance, as a practicing family physician, I witnessed a patient who had an inflammatory condition who was not improving on a specific class of medications. To get to the bottom of why this was happening, the patient took a pharmacogenomic test and found that these medications did not metabolize well. After switching to a different class of medications the patient saw significant improvement in symptoms.
By moving away from the indiscriminate prescription of medications and instead, incorporating patient-specific genetic insights on how they are likely to metabolize and respond to drugs, we can significantly improve patient outcomes. The future of healthcare isn’t about treating symptoms with more pills; it’s about getting the right treatment to the right patient at the right time.
Polypharmacy and its consequences
More than 131 million people — 66% of adults in the United States — use prescription drugs. Polypharmacy is also increasingly common due to the aging population and more medications associated with the rise in chronic diseases such as diabetes, hypertension, and heart disease.
Many people with multiple prescriptions receive them from different physicians, who are often unaware of what else their patients are taking. This lack of coordination can put patients at risk for negative outcomes, as the more drugs a person takes, the greater the risk that those drugs interact poorly with one another.
One of the most significant risks of polypharmacy is the potential for adverse drug reactions (ADRs). For example, a patient taking blood thinners along with certain painkillers may experience an increased risk of bleeding. Similarly, combining medications that affect the central nervous system can lead to confusion, dizziness, and falls, particularly in older adults.
For patients, multiple medications can also be overwhelming, leading to medication non-adherence, where patients do not take their medications as prescribed. This can result from various factors, including the complexity of the medication regimen, forgetfulness, side effects, and lack of understanding of the importance of each medication. Non-adherence can lead to medical conditions getting worse and higher mortality rates.
Polypharmacy-related ADRs and medication non-adherence are major factors in increased hospitalizations. Studies have shown that patients taking multiple medications are more likely to be hospitalized due to these complications. Hospital stays affect the patient’s quality of life and significantly burden healthcare systems. Preventing unnecessary hospitalizations through better medication management is therefore crucial.
The financial burden of polypharmacy is also significant. The cost of multiple medications can overwhelm patients, particularly those on fixed incomes. Additionally, all of the aforementioned consequences increase overall healthcare costs. These financial pressures can lead patients to skip doses or not fill prescriptions, worsening their health issues.
Pharmacogenomics and its benefits to reduce polypharmacy
Pharmacogenomics tailors medications and dosages to a patient’s unique genetic profile, ensuring that the treatment is highly effective and minimizes adverse effects. This stands in stark contrast to the one-size-fits-all approach of polypharmacy, which does not consider individual genetic variations.
By identifying genetic factors that influence drug metabolism, pharmacogenomics reduces the risk of adverse drug reactions and improves patient safety. This is especially important for vulnerable populations over 65. It also ensures that patients receive medications that are genetically suited to work best for them, resulting in higher treatment success rates.
While genetic testing has an upfront cost, pharmacogenomics reduces long-term healthcare expenses by minimizing hospitalizations due to ADRs, reducing ineffective treatments, and optimizing drug use.
Amplifying pharmacogenomics with team-based care
However, the benefits of pharmacogenomics don’t happen in a vacuum. There is increasing evidence that a team-based clinical care model, especially for the most complicated patients, can reduce the consequences of polypharmacy when paired with pharmacogenomics. Team-based care is a multi-faceted approach that requires collaboration between patients, healthcare providers, and the healthcare system with activities that include:
- Ongoing medication reviews – Regular medication reviews by healthcare providers can identify unnecessary medications and potential drug interactions. If patients have recently been hospitalized or in a care facility, medication reconciliation during transitions of care ensures that all medications are reviewed—especially the mix of new and old prescriptions—and adjusted as needed.
- Deprescribing – When patients need to come off of medications or begin to stop taking medications that were only prescribed in the short term, the process is called deprescribing. The process includes tapering or stopping medications that are no longer necessary or pose more risks than benefits. Deprescribing should be done carefully and systematically, with close monitoring of patients’ conditions.
- Patient education – Educating patients about their medications, including their purpose, dosage, and potential side effects, can improve adherence and empower patients to actively participate in their care. When patients have clear instructions and support they can better manage medication regimens.
- Use of technology – Electronic health records (EHRs) and medication management apps have been around for a long time and can act as a check-and-balance system. In the context of team-based care, they enhance communication between providers and help track patients’ medication use. EHRs can alert providers to potential drug interactions and duplications, improving the overall safety of medication management.
- Pharmacist involvement – Pharmacists play a crucial role in managing polypharmacy as the most frequently visited provider in a patient’s community. They can conduct comprehensive medication reviews, provide counsel to patients, and collaborate with other providers to optimize medication therapy.
In addition to identifying patients’ medications and health risks, team-based care, more importantly, incorporates other critical insights from pharmacogenomics. This information allows their care team to develop a Medication Action Proposal, or MAP, with suggestions to modify patients’ drug regimens, lower their risk profile, address chronic conditions and, when needed, identify opportunities to reduce net drug costs. Patients’ routines are then reviewed regularly by their physicians and pharmacists to confirm the medications are achieving the targeted objectives and that no new issues have developed.
Patients deserve data-driven decisions
Our healthcare system needs to evolve from reactive, one-size-fits-all medication management to a more personalized, preventative, and effective model. We cannot change the fact that some patients must take multiple drugs, but we can certainly change how we manage it with careful coordination and communication among healthcare providers, and personalized medicine practices such as pharmacogenomics. Implementing integrated healthcare systems and encouraging open communication between providers, pharmacists, and patients can improve medication management and safety. When the stakes are patients’ health, the U.S. healthcare system must embrace open communication and data-driven prescribing.
Photo: Stas_V, Getty Images
A distinguished physician and respected healthcare innovator, Dr. Steve Goldberg serves as the Chief Clinical Advisor for DecisionRx and Chief Medical Officer for HealthTrackRx. He previously served as Chief Health Officer and Vice President of Medical Affairs at Quest Diagnostics and, preceding that, more than a decade in leading roles of several major health plans, including Chief Medical Officer at WellCare Health Plans, Senior Medical Director at Coventry Health Care, Chief of Medical Affairs at Express Scripts, Corporate Medical Director, Clinical Policy and Quality at Humana, Regional Chief Medical Officer at Excellus BCBS, Network Medical Director at Aetna Health Plans, and Medical Director at Kaiser Permanente NE. In 2020, Dr. Goldberg was ranked No. 39 in Modern Healthcare’s 2020 “100 Most Influential People in Healthcare.” He graduated from Georgetown University (BA), Sidney Kimmel Medical College, Thomas Jefferson University (MD), and Binghamton University (MBA).
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