Original Article
Polypharmacy, defined as taking five or more drugs, is inadequate in the cardiovascular setting

https://doi.org/10.1016/j.jclinepi.2018.05.002Get rights and content

Abstract

Background

By how much polypharmacy (defined by number of drugs) differs from polyactive ingredient use (defined by the number of pharmacologically active ingredients) has not been assessed.

Objectives

To compare the extent of polypharmacy vs. polyactive ingredients among patients taking cardiovascular (CV) medicines.

Methods

Prospective, 10-year follow-up study conducted among 880 participants of the CoLaus study taking CV drugs at baseline. Polypharmacy was defined as the use of five or more CV medicines; polyactive ingredient use was defined as the use of five or more pharmacologically active CV ingredients.

Results

The prevalence of polypharmacy increased from 1.4% (0.7–2.4) (prevalence rate [95% confidence interval]) at baseline to 11.9% (9.9–14.3) at follow-up, and the prevalence of polyactive ingredients increased from 2.4% (1.5–3.6) at baseline to almost 17.6% (15.2–20.3) at follow-up. The prevalence of combination drugs increased from 15.7% (13.3–18.3) at baseline to 25.9% (23–28.9) at follow-up, and the prevalence of three-component combination use increased from 0.1% (0.0–0.6) at baseline to 2.3% (1.4–3.5) at follow-up. At baseline, nine of 21 participants on polyactive ingredients were not considered as being on polypharmacy; at follow-up, the rate was 50 of 155 participants.

Conclusion

Among individuals taking CV drugs, polypharmacy as defined by the number of drugs underestimates the prevalence of individuals taking five or more pharmacologically active drugs. Polypharmacy should no longer be based on the number of drugs but on the number of pharmacologically active drugs.

Introduction

Population aging is associated with an increased frequency of multimorbidity and evidence-based guidelines recommend using several drugs in the treatment of a single condition. Both phenomena have made medication therapy particularly challenging as a growing number of patients take several drugs, which is referred to as polypharmacy [1], [2], [3].

Although the term polypharmacy has been used for decades, a precise definition is lacking. The cutoff points, methods, and settings for exploring polypharmacy vary widely [4], [5]. Most studies used a cutoff point of five or more drugs to define polypharmacy [6], [7]. A definition based on the number of units or of pharmacologically active ingredients remains an open debate. Indeed, the emergence of drugs combining two or more pharmacologically active ingredients (e.g., polypill for cardiovascular diseases [CVDs] prevention) might change the concept of polypharmacy. By how much polypharmacy (defined by number of drugs) differs from polyactive ingredients (defined by the number of pharmacologically active ingredients) has not been assessed.

Thus, this study aimed to compare the prevalence and 10-year trends of polypharmacy vs. polyactive ingredients among community-dwelling subjects taking CV medicines.

Section snippets

Study population and design

The CoLaus study is an ongoing prospective survey investigating the biological and genetic determinants of CV risk factors and CVD in the population of Lausanne, Switzerland. Detailed descriptions of the study design have been reported elsewhere [8]. A simple, nonstratified random sample of the Lausanne population aged 35–75 years was drawn. Recruitment began in June 2003 and ended in May 2006 and included 6,733 participants, with a participation rate of 41%. The follow-up was conducted

Participants

Of the 1,332 participants eligible for the study (taking CV drugs), 880 (66.0%, 441 men) were included (Fig. 1). Included participants were younger, more frequently born in Switzerland and had a higher prevalence of former smokers, although no differences were found regarding gender or alcohol consumption Supplemental Table 2.

Trends in prevalence of polypharmacy, polyactive ingredient, and cardiovascular drug combinations

The trends in the number of drugs, pharmacologically active ingredients, and prevalence of polypharmacy, polyactive ingredient use, and CV drug combinations at baseline

Discussion

In 10 years, the prevalence of both polypharmacy and polyactive ingredient increased among community-dwelling CV patients. If at baseline, the prevalences of polypharmacy and polyactive ingredient were rather close, 10 years afterward the prevalence of polyactive ingredient was significantly higher than the prevalence of polypharmacy. Furthermore, at follow-up, a significant number of participants taking five or more pharmacologically active drugs were not considered as being on polypharmacy.

Conclusion

Among individuals taking CV drugs, polypharmacy as defined by the number of drugs underestimates the prevalence of individuals taking five or more pharmacologically active ingredients. Polypharmacy should be counted as the number of pharmacologically active ingredient.

Acknowledgments

Authors' contributions: N.A. suggested the topic and wrote most of the article; P.M.V. collected data, made the statistical analysis, and reviewed the article for important intellectual content. P.M.V. had full access to the data and is the guarantor of the study. Both authors have read and approved the final version of the article.

References (14)

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Conflict of interest: The authors report no conflict of interest.

Ethical statement and consent: The institutional Ethics Committee of the University of Lausanne, which afterward became the Ethics Commission of Canton Vaud, approved the baseline CoLaus study (reference 16/03, decisions of 13th January and 10th February 2003); the approval was renewed for the second (reference 26/14, decision of 11th March 2014) follow-up. The study was performed in agreement with the Helsinki declaration and in accordance with the applicable Swiss legislation. All participants gave their signed informed consent before entering the study.

Funding: The CoLaus study was and is supported by research grants from GlaxoSmithKline, the Faculty of Biology and Medicine of Lausanne, and the Swiss National Science Foundation (grants 33CSCO-122661, 33CS30-139468 and 33CS30-148401). N.A. is supported by an excellence scholarship from the Swiss Federal Government (Reference No. 2016.1098). The funding sources had no contribution to the study design, analysis, and interpretation, as well as writing the report and decision to submit the article for publication.

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