While the world witnesses a constant evolution in style, governance, and personal aesthetics, a contrasting trend emerges in the realm of healthcare. A significant number of patients find themselves in a cycle where their medical prescriptions remain unchanged over time, with the only variation being an increase in the quantity of medications they must manage.
Polypharmacy, the concurrent use of multiple medications by a patient, particularly afflicts the elderly and those with multiple chronic conditions. While it can be a necessary aspect of managing complex health issues, it often leads to a precarious juggling act of medications that can do more harm than good.
Polypharmacy isn’t just a concern for the elderly; it also affects the working-age population. Chronic conditions that require long-term medication management often begin in midlife, potentially leading to premature medication overload and diminishing the vitality of the workforce.
While specific data on polyphramacy in South Africa is limited, insights can be drawn from neighboring countries like Nigeria and Ethiopia, where it is prevalent and associated with adverse drug events, hospital admissions, and potentially inappropriate medication use. These issues underscore the importance of addressing polypharmacy as a public health concern.
The Over-prescription Epidemic: Navigating the Medication Maze
Over time, a medication’s benefit may decline while its harms increase.
There are a pretty limited number of drugs for which the benefit-harm balance never changes.
In the labyrinth of modern medicine, certain medications stand out for being handed out too liberally. Antibiotics, for instance, are often prescribed unnecessarily, contributing to the growing problem of antibiotic resistance. Painkillers, acid reflux medication, hormone therapies such as levothyroxine, and antidepressants also frequently make the list of drugs that are dispensed more often than medical wisdom would dictate.
In the USA, adults are particularly susceptible to the pitfalls of over-prescription, with a staggering 42% of those over 65 taking five or more medications. This polypharmacy can lead to a domino effect of adverse drug events, hospitalizations, and even increased mortality rates. It’s a sobering thought that in 2018 alone, an estimated 10 million older Americans suffered from adverse drug events, with over a quarter of a million ending up in the hospital.
The South African context over-prescribing is similar. It is common to see elderly people swallowing handfuls of medicines every day. In 2022 the Journal of Pharmaceutical Policy and Practice published a South African study on polypharmacy, where 250 random geriatric patient’s prescriptions were looked into. The study found that each patient was taking an average of 4.25 prescription medications concurrently. The study concluded that more research needs to be conducted in this regard.
The Case for De-prescribing
De-prescribing is the deliberate process of tapering or stopping medications that may no longer be beneficial or could be harmful. It is a critical step towards reducing the risks associated with polypharmacy and improving patient outcomes.
Involving patients and their caregivers in the de-prescribing process is crucial. Many are open to reducing their medication load, especially if they understand they can resume a drug if necessary. However, the process must be managed carefully to avoid withdrawal symptoms and ensure the continued management of their health conditions.
The Unseen Side Effects: Nutrient Depletion by Common Medications
In the realm of allopathic medicine, prescription and over-the-counter medications stand as pillars of disease management and symptom relief. However, beneath the surface of their therapeutic benefits lies a less discussed consequence: nutrient depletion. Polypharmacy not only increases the risk of drug-drug interactions, but drug-nutrient interactions. This phenomenon occurs when medications interfere with the body’s natural ability to absorb, synthesize, or utilize essential vitamins and minerals, leading to a silent epidemic of nutritional deficiencies that can exacerbate health issues and diminish quality of life.
The consequences of drug-induced nutrient depletion are not uniform; they vary widely among individuals taking the same medication. Some patients may experience significant reductions in essential nutrients, leading to additional health complications, creating a cascading effect of negative health outcomes. For instance, elderly patients on multiple medications are at a higher risk of deficiencies in vitamins such as B1, B2, B6, B9, and B12. These deficiencies can lead to a range of new health issues, from anemia to cognitive decline.
In June the TNHA published an article titled Drug-Induced Nutrition Depletion – Replenish Your System, which delves deeper into this subject.
Mechanisms of Nutrient Depletion
The mechanisms by which medications deplete nutrients are multifaceted and not fully understood. Some drugs may impair the digestive system’s ability to absorb nutrients from food, while others may increase the body’s demand for certain nutrients, leading to a depletion of reserves. This complex interaction between pharmacology and physiology underscores the need for greater awareness and proactive management of nutrient levels in patients undergoing long-term medication treatments.
Tools and Support for De-prescribing and Supplementation
Healthcare professionals have access to various tools and guidelines to aid in the de-prescribing process but this practice seldom happens in the 15-minute doctor consultation model, or in the queue in a busy pharmacy. Pharmacists and healthcare professionals need to play a pivotal role in this process, providing expertise in medication management and assisting in the development of de-prescribing plans. Their input can lead to a reduction in inappropriate prescribing and support the safe implementation of medication changes.
Additionally, they should be applying a more personal approach, recommending micro-nutrient supplementation so that their patients and clients can put back that which is lost from nutrient depletion caused by certain classes of medicines used prior, and recommend concomitant supplementation with chronic medications known to cause nutrient depletion.
It is also crucial to identify at-risk populations and implement preventive measures to ensure that patients maintain optimal nutrient levels while on their medications. This proactive stance can help mitigate the adverse effects of drug-induced nutrient depletion and improve overall therapeutic outcomes.
In a recent report by the Council for Responsible Nutrition in the USA, titled Supplements to Savings – Health Care Cost Savings from the Targeted Use of Dietary Supplements 2022–2030, Frost & Sullivan examined evidence that demonstrates that the use of key dietary supplement ingredients can reduce the direct and indirect medical costs associated with coronary artery disease (CAD), age-related cognitive decline disorders, age-related eye disease, diabetes, osteoporotic fractures, irritable bowel syndrome, and inadequate choline intake among expectant mothers.
They concluded that there is a marked shift, driven by healthcare stakeholders looking for better ways to control escalating health care costs by identifying people at higher risk of disease early, and working to minimize their chances of experiencing costly events, using more targeted or personalized solutions. One solution that is accessible to Americans today is the availability dietary supplement products that have been scientifically shown to help reduce this risk.
We at the TNHA believe that beyond these demonstrable cost savings in preventing late-in-life chronic diseases with the use of inexpensive micro-nutrient supplements, polypharmacy needs to be tackled with the urgency it deserves. Equally drug-nutrient interactions need to be addressed with prescribing standards of care created for medical practitioners and pharmacists, where appropriate supplementation is advised and such substances be classified in the same way essential medicines are listed. Implementing these achievable recommendations will save our tax-payers billions of rand each year in healthcare costs, and greatly increase our citizen’s health, wellness and quality of life.
Conclusion
The practice of de-prescribing is a nuanced and patient-specific endeavor that balances the benefits and risks of medication use. When done correctly, it can lead to improved mortality rates, quality of life, and cognitive function, ultimately fostering a more judicious use of medicines. While medications are indispensable tools in the fight against illness, it is imperative to also recognize and address the hidden cost of nutrient depletion they may impose.
Through increased awareness, diligent monitoring, and strategic supplementation and good dietary advice, we can ensure that the benefits of medications are not overshadowed by the detrimental effects on nutritional health. As we continue to advance in the fields of medicine and nutrition, let us also not overlook the foundational role of nutrition in supporting the body’s resilience and recovery.
By Anthony Rees, Chairman, TNHA