Highlights
- •Polypharmacy is a prevalent concern among adults who may be taking a combination of medications.
- •This may result in various medication-related problems such as adverse effects, drug interactions, inappropriate therapy, or nonadherence.
- •It is important for health practitioners to be cognizant of the tools and methods to manage polypharmacy-related issues to optimize patient outcomes.
Abstract
Polypharmacy is a common observation among older adults secondary to their complex medical needs requiring management with 1 or more medications. The use of numerous medications may result in medication-related problems such as inappropriate indications, therapeutic duplication, adverse effects, drug interactions, unnecessary medications, poor adherence, and a strain on health care resources. Nurse practitioners will be required to review and streamline the appropriate and safe use of medications in patients to minimize some of the highlighted concerns. This article uses a case-based approach to showcase various issues that a nurse practitioner may encounter as it relates to polypharmacy and pharmacotherapeutic considerations. Tools are also explored to assess polypharmacy in the field.
Keywords
American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hours (including 1.0 hour of pharmacology credit), approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.
Polypharmacy is a common health concern among older adults. Previous literature has reported an average rate of 40% to 50% in this population.
1
,2
Polypharmacy refers to the use of multiple medications in a patient, commonly an older adult. Interestingly, there is a lack of a standard definition for such a term.- Woodruff K.
Preventing polypharmacy in older adults.
Am Nurse Today. 2010; 5
www.americannursetoday.com/preventing-polypharmacy-in-older-adults
Date accessed: October 5, 2019
3
,4
Polypharmacy has been described as the co-prescribing of multiple medications, the inappropriate use of medication(s), using medications without a clinical indication, visiting multiple pharmacies, and the use of 5 or more medications, and the list goes on.3
,4
There is also literature that further delineates the degree, duration, and various settings of polypharmacy.3
,4
Age, ethnicity, health status, education, and access to pharmacy are examples of varying risk factors associated with this medication-related concern.3
Regardless of the scenario, polypharmacy negatively affects patient care by potentially increasing health care costs and the risk of drug-related issues. Examples of such issues include nonadherence, therapeutic duplication, unnecessary drug exposure, adverse drug events, and drug interactions.5
,6
In fact, a study conducted by Abe et al7
concluded that polypharmacy resulting in symptomatic adverse drug events was a preventable risk factor for hospital admission among older adults.The following is a case-based approach to evaluating potentially inappropriate medication (PIM) use secondary to polypharmacy and addressing various pharmacotherapeutic considerations. This includes a discussion on the advantages and disadvantages of the therapies at hand based on the patient-related effects of the medications, safety concerns, drug interactions, and clinical practice guideline recommendations. Assessment tools used in the setting of polypharmacy are also explored.
Patient Case
A 74-year-old obese African American female (height = 5’6” and weight = 90 kg) has a past medical history of chronic kidney disease (CKD) stage 2, glaucoma, heart failure with reduced ejection fraction (HFrEF), hyperlipidemia, hypertension (HTN), osteoarthritis, and type 2 diabetes mellitus (T2DM). The patient also occasionally complains of constipation, heartburn, and insomnia for which she takes medications as needed. She has no known drug allergies. Based on the latest medication profile, the patient is receiving the medications listed in Table 1.
Table 1A List of Medications the Patient Is Currently Taking for Each Health Problem
| Health Problem | Medication Name | Instructions |
|---|---|---|
| Constipation | Docusate | 100 mg by mouth 3 times daily as needed |
| Glaucoma | Timolol (ophthalmic) | 1 drop in both eyes twice daily |
| Heartburn | Famotidine | 20 mg by mouth twice daily |
| Calcium carbonate antacid | 1 tablet as needed | |
| HFrEF/HTN | Carvedilol | 12.5 mg by mouth twice daily |
| Furosemide | 40 mg by mouth daily | |
| HLD | Atorvastatin | 20 mg by mouth daily |
| Insomnia | Zolpidem | 10 mg by mouth at bedtime as needed |
| T2DM | Metformin | 500 mg by mouth twice daily |
| Osteoarthritis | Acetaminophen | 500 mg by mouth 4 times daily as needed |
| Ibuprofen | 200 mg by mouth 4 times daily as needed |
HFrEF = heart failure with reduced ejection fraction; HLD = hyperlipidemia; HTN = hypertension; T2DM = type 2 diabetes mellitus.
The following relevant vital signs and laboratory data are provided:
- •Vital signs: blood pressure = 150/85 mmHg and heart rate = 78 beats/min
- •Renal function and electrolytes: serum creatinine = 1 mg/dL, blood urea nitrogen = 15 mg/dL, urinary albumin-to-creatinine ratio ≥ 300 mg/g, estimated glomerular filtration rate (eGFR) = 64 mL/min/1.73 m2, and serum potassium = 3.5 mEq/L
- •Lipid panel: total cholesterol = 245 mg/dL, high-density lipoprotein = 55 mg/dL, low-density lipoprotein = 190 mg/dL, and triglycerides = 150 mg/dL
- •Liver enzyme tests: aspartate aminotransferase = 32 IU/L and alanine aminotransferase = 35 IU/L
A list of PIMs as it pertains to the patient case is described in Table 2
8
, 9
, 10
, 11
, 12
, 13
, - Grundy S.M.
- Stone N.J.
- Bailey A.L.
- et al.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
Circulation. 2019; 139: e1082-e1143
14
, 15
, 16
, NKF and NSAID Alliance declares NSAID awareness week.
https://www.kidney.org/news/nkf-and-nsaid-alliance-declares-nsaid-awareness-week-august-24-%E2%80%93-28
Date accessed: June 28, 2019
17
, 18
, 19
alongside a description of the pharmacotherapeutic concerns and recommendations.Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
Table 2Case-Based Analysis of Potentially Inappropriate Medications (PIMs)
8
, 9
, 10
, 11
, 12
, 13
, - Grundy S.M.
- Stone N.J.
- Bailey A.L.
- et al.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
Circulation. 2019; 139: e1082-e1143
14
, 15
, 16
, NKF and NSAID Alliance declares NSAID awareness week.
https://www.kidney.org/news/nkf-and-nsaid-alliance-declares-nsaid-awareness-week-august-24-%E2%80%93-28
Date accessed: June 28, 2019
17
, 18
, 19
Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
| PIMs | Description | Management Strategies |
|---|---|---|
| Timolol, carvedilol |
|
|
| Metformin | ||
| Zolpidem | ||
| Atorvastatin |
| |
| Ibuprofen |
|
|
| Docusate |
|
|
CKD = chronic kidney disease; HF = heart failure; HTN = hypertension; LDL = low-density lipoprotein; NSAID = nonsteroidal anti-inflammatory drug; T2DM = type 2 diabetes mellitus.
Discussion
Despite the varying definitions, polypharmacy is a term generally associated with patients who are taking multiple medications.
1
, 2
, - Woodruff K.
Preventing polypharmacy in older adults.
Am Nurse Today. 2010; 5
www.americannursetoday.com/preventing-polypharmacy-in-older-adults
Date accessed: October 5, 2019
3
, 4
Older patients with multiple comorbidities often require management with more than one medication, inherently increasing the risk of polypharmacy and the negative outcomes previously identified. Beyond prescription products, over-the-counter medications and dietary supplements can contribute to this complex health matter.20
,21
The medication management process in the older population is multifaceted with considerations for drug dosing, drug interactions, adverse effects, adherence, social issues, clinical practice guidelines, and altered physiology, among other factors.There are various tools described in the literature that may be used as a guide to identifying and assessing patients for polypharmacy-related issues.
22
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One of the most commonly used tools is the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.22
The Beers Criteria consists of 5 categories of medications to be avoided or used with caution in older adults: medications that are potentially inappropriate, medications that are potentially inappropriate with certain conditions, medications that should be used with caution, potentially clinically important drug-drug interactions that should be avoided, and medications that should be avoided or have their dosage reduced with varying levels of kidney function.32
The list is based on various trials and expert opinions and consists of 88 drug/drug classes. When examining the impact of adverse drug events on hospitalizations in older adults, 6.6% of adverse drug-related hospitalizations were caused by medications on the Beers Criteria.23
Limitations to the Beers Criteria include that it does not provide information on underprescribed medications and alternative medications.Unlike the Beers Criteria, the STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatments) criteria provide guidance on inappropriate medications as well as medications that are underprescribed.
24
,25
The STOPP/START includes 80 different criteria for stopping and 34 different criteria for starting medications. The STOPP/START criteria are organized by organ system (eg, cardiovascular and central nervous system), adverse events (eg, medication that increases risk of falls and antimuscarinic/anticholinergic), and other drug classes (eg, vaccines and analgesics). When comparing the Beers Criteria with the STOPP/START criteria in older hospitalized patients, the STOPP criteria identified more PIMs.24
,25
Additionally, a greater proportion of those PIMs identified with the STOPP/START criteria were associated with an adverse drug event.24
,25
The STOPP/START criteria does not suggest alternative medications or provide renal dosing adjustments.The FORTA (Fit fOR The Aged) classification, which was initially developed in Germany, is another tool that can be used to screen for PIMs.
26
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, 28
, 29
, 30
Like the STOPP/START criteria, the FORTA classification includes both recommendations for PIMs and underused medications and is categorized by disease state. All drugs/drug classes are ranked from a scale of A through D with A as indispensable, B as beneficial, C as questionable, and D as avoid. Wehling et al28
showed that the use of the FORTA criteria resulted in significant improvements in over/undertreatment, adverse drug reaction, and activities of daily living in hospitalized patients. The FORTA has further expanded to include geriatric/pharmacologic expertise from other European countries to become the EURO-FORTA criteria. The EURO-FORTA list includes 264 drugs/drug classes and 26 diagnoses.29
Limitations of the FORTA list include limited rationale for recommendations and no information on drug-drug interactions, drug-disease interactions, and renal dosing adjustments.Although more drug-specific tools are available, they all have strengths and limitations to their use. The combinations of these tools may be able to circumvent some of these limitations. Various drug interaction tools (eg, Lexicomp Online
9
and IBM Micromedex36
) can also be used to help the busy clinicians identify interactions with therapy. Many of these tools will incorporate information from the Beers Criteria and STOPP/START criteria into their recommendations. Continued advancements in technology will improve the practical implementation of these tools into clinical practice and are currently being studied and developed.IBM Micromedex Healthcare Series [internet database]. Greenwood Village, CO: Thomson Healthcare. Update periodically.
https://www.micromedexsolutions.com/home/dispatch
Date accessed: October 6, 2019
Although these tools (eg, Beers Criteria, STOPP/START, and FORTA) are useful and provide detailed drug information, they must be used in conjunction with good clinical judgment. Compared with the aforementioned tools that provide guidance on specific medications to avoid, underprescribed medications, dosing adjustments, and drug interactions, there are clinical decision algorithms or questionnaires that can be used. Many of these algorithms or questionnaires require more judgment because they do not provide any drug-specific information. Some examples of these include The Good Palliative-Geriatric Practice Algorithm,
30
Medication Appropriateness Index,31
and the 10-step drug minimization guide.32
Based on the medication profile, the patient has several comorbidities for which she is taking a total of 11 different medications, 7 routine medications for the management of chronic health conditions, and 4 medications as needed for other ailments. The combination of these medications warrants further evaluation to ensure safe, continued use. For instance, some medications are indicated and appropriate for the management of chronic medical conditions, but their continued use may require increased monitoring. Some medication regimens may need dosing adjustments because of patient-specific characteristics and physiologic changes observed in older adults. There may also be a need to deprescribe and prescribe other medications because of current literature and practice guidelines to optimize patient outcomes. As such, it is essential for the nurse practitioner (NP) to systematically evaluate every aspect of the pharmacotherapy used in patients to avoid polypharmacy and its negative consequences.
24
Examples of detection, assessment, and management strategies for medication-related issues (increased monitoring, Beers Criteria, deprescribing, and clinical practice guidelines) as they apply to the patient case are as follows.Examples of Increased Monitoring
Beta Blockers: Timolol and Carvedilol
The coadministration of ophthalmic timolol and oral carvedilol results in a potential drug-drug interaction.
8
,9
Ophthalmic timolol is a commonly prescribed beta blocker used for glaucoma that is associated with local effects of the eye (eg, burning, itching, dryness, or visual disturbances).9
Despite its topical administration, ophthalmic timolol is absorbed into the systemic circulation and may result in serious cardiac effects (eg, bradyarrhythmias, hypotension, and heart block).8
These effects may be amplified when coadministered with other medications and increase the risk of falls and syncope.8
,9
In this case, the patient is receiving oral carvedilol for the management of HTN and HFrEF; however, she still has an elevated blood pressure and normal heart rate while on the combined regimen. Prospectively, it is advised that the patient be monitored for the additive adverse effects of these products with parameters such as heart rate and blood pressure.9
Additional therapy for the management of blood pressure will be discussed within the clinical practice guidelines section.Beta blockers also have the potential to affect glucose levels. In patients with diabetes, it may mask the signs and symptoms of this adverse effect.
9
Although it is not a contraindication to use this drug class in our patient who is receiving carvedilol and has T2DM, additional monitoring is warranted to ensure that the targeted glycemic goals are achieved safely. The patient should also be educated on the management of hypoglycemia as delineated by the American Diabetes Association.15
Metformin
Metformin is an oral blood glucose–lowering agent that is renally eliminated.
9
Renal impairment and unstable heart failure are notable risk factors for metformin-induced lactic acidosis.9
,11
In a patient who is older, has kidney disease, has otherwise stable heart failure, and is simultaneously receiving metformin, the NP should monitor for signs and symptoms of an adverse outcome including malaise, myalgia, respiratory distress, and somnolence.9
This is in addition to the patient’s renal function and overall glycemic control.15
It is also important to be mindful of the most recent labeling recommendations that account for a patient’s renal function while considering eGFR as follows: do not initiate metformin in patients with an eGFR < 30 mL/min/1.73 m2; it is not recommended to initiate metformin in those with an eGFR between 30 and 45 mL/min/1.73 m2; for those who are already on metformin and the eGFR falls below 45 mL/min/1.73 m2, metformin should be evaluated for risks versus benefits and closely monitored; and metformin should be discontinued if the eGFR fall below 30 mL/min/1.73 m2.9
,10
Our patient has an eGFR of 64 mL/min/1.73 m2 and can be continued on this therapy at this time. Should the patient’s kidney disease advance or the heart failure become unstable, alternative pharmacotherapy to manage T2DM may need to be sought.Example of STOPP/START and Beers Criteria
Zolpidem
Zolpidem is a commonly prescribed nonbenzodiazepine sedative hypnotic used for the management of insomnia. It has a relatively quick onset of action of approximately 30 minutes to achieve its effects but is associated with significant safety concerns.
9
,12
This includes neuropsychiatric symptoms, visual and auditory hallucinations, delirium, amnesia, sleepwalking, and nocturnal eating.9
,12
Zolpidem is also a product listed in the American Geriatrics Society Beers Criteria and STOPP/START criteria because of its risk of delirium, falls, and fractures in older adults.22
In this patient case, the use of zolpidem should be re-evaluated with considerations of stopping it.24
,25
If stopping it, consider slowly titrating the dose downward. If the patient requires additional therapy, cognitive behavioral therapy or pharmacologic alternatives such as ramelteon may be considered.37
If the therapy is continued, close monitoring of the noted effects should be performed. In this patient, if zolpidem is to be continued and no safer alternative is available, it is suggested to decrease the dose to 5 mg because female patients have been found to be slower metabolizers of the product, resulting in prolonged effects of zolpidem.9
,12
,22
Example of Deprescribing
Docusate
An example of deprescribing is docusate.
38
Docusate is a stool softener that works by lowering surface water tension of the stool, thus softening it.18
,19
Historically, this product has been widely used as a laxative, although the data to support its efficacy are lacking.Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
18
,19
In a randomized controlled trial comparing docusate versus psyllium, docusate had fewer bowel movement frequency compared with psyllium.Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
39
Because of its lack of efficacy, many practice settings have removed the product from formulary.19
For this patient, consider deprescribing docusate from the medication regimen to reduce the polypharmacy-related issues because the patient is taking many other medications that are essential for chronic medical conditions.Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
The patient in this case is 74 years old, and as one gets older, there are physiologic changes that occur involving the gastrointestinal tract. Such examples include decreased gastrointestinal motility that can lead to constipation.
39
,40
A common alternative laxative can be considered in this patient is a bulk-forming laxative such as psyllium.41
If the patient is taking bulk-forming laxatives and continues to experience constipation, then a stimulant or osmotic laxative (eg, polyethylene glycol) may be added.19
,Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.
41
Examples of Clinical Practice Guidelines
Statins
The patient has several high-risk conditions (low-density lipoprotein = 190 mg/dL, T2DM, HTN, age ≥ 65 years, and heart failure) for future atherosclerotic cardiovascular disease events.
13
, - Grundy S.M.
- Stone N.J.
- Bailey A.L.
- et al.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
Circulation. 2019; 139: e1082-e1143
14
, 15
According to the American College of Cardiology and American Heart Association, the patient is eligible for a high-intensity statin to reduce the risk of cardiovascular disease. This may include atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily.14
,15
The patient is currently receiving atorvastatin 20 mg daily, which is considered a moderate-intensity dosing strategy.14
,15
Considering the latest recommendations, the statin dose should be reassessed in this patient and, if tolerated, may be titrated to a higher-intensity dose.14
,15
Because of her age, the patient is also at a higher risk of adverse reactions and should be monitored for any adverse effects related to dose escalation such as muscle pain, liver enzyme tests, and lipid profiles.9
Nonsteroidal Anti-inflammatory Drugs
Patients with CKD are at risk for developing end-stage kidney disease. As such, medications that are potentially harmful to the kidneys should be avoided. In this case, ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that may lead to decreased plasma flow to the kidney by decreasing prostaglandin synthesis, an important step in regulating the vasodilatory property within the glomerulus.
42
For this reason, the National Kidney Foundation does not recommend NSAIDs to be used in the setting of CKD.16
For this patient, an NSAID should be avoided because of 1) its potentially nephrotoxic effects, and 2) its associated and increased risk of gastrointestinal bleeds in older adults.NKF and NSAID Alliance declares NSAID awareness week.
https://www.kidney.org/news/nkf-and-nsaid-alliance-declares-nsaid-awareness-week-august-24-%E2%80%93-28
Date accessed: June 28, 2019
16
,NKF and NSAID Alliance declares NSAID awareness week.
https://www.kidney.org/news/nkf-and-nsaid-alliance-declares-nsaid-awareness-week-august-24-%E2%80%93-28
Date accessed: June 28, 2019
17
This is an extremely important consideration when caring for older adults with high risk for polypharmacy-related issues. The patient also has cardiac issues to which NSAIDs should be avoided overall.Angiotensin-converting Enzyme Inhibitor/Angiotensin Receptor Blocker
To slow the progression of CKD, an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) is recommended. According to the American Diabetes Association, these agents are recommended in patients with 1) a urinary albumin-to-creatinine ratio of 30 to 299 mg/g or 2) a urinary albumin-to-creatinine ratio ≥ 300 mg/g, and/or an estimated eGFR < 60 mL/min/1.73 m2.
15
Similarly, the American Heart Association and the American College of Cardiology recommend these agents for the management of HTN in patients with comorbidities such as HFrEF and CKD.14
With the latter, candidates for ACEi or ARB therapy include 1) CKD stage 3 or higher, or 2) CKD stage 1 or 2 with a urinary albumin-to-creatinine ratio of ≥ 300 mg/g.14
,15
Collectively with a past medical history of CKD, HTN, HFrEF, and T2DM and the current blood pressure, the patient is a candidate for ACEi or ARB therapy. The electrolytes are within normal limits, and there are no other factors that would exclude the patient from this therapy at this time. While on therapy, renal function (albuminuria and eGFR), electrolytes (serum potassium), cough, angioedema, and blood pressure should be monitored routinely. The long-term blood pressure goal is dependent on the guidelines referenced and may range from a systolic pressure of 130 to 140 mmHg and a diastolic pressure of 80 to 90 mmHg.14
,15
Antiplatelet Agents
For the reduction of cardiovascular morbidity and mortality, antiplatelet agents are often considered. Per the American Diabetes Association guidelines, aspirin is recommended as a secondary prevention measure in patients with diabetes and a history of atherosclerotic cardiovascular disease.
14
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Aspirin may also be considered as a primary prevention measure in patients ≥ 50 years with diabetes at low bleeding risk and at an increased cardiovascular risk (family history of atherosclerotic cardiovascular disease, HTN, dyslipidemia, smoking, and CKD/albuminuria). Use in patients ≥ 70 years is debatable because of a greater risk versus benefit of initiating this agent and would require such considerations of the patient’s gastrointestinal bleeding risk and life expectancy. Applying these recommendations to our case, albeit a commonly prescribed agent, the addition of aspirin would have to be re-evaluated by the clinician alongside the patient.14
,15
Implications for Practice
The provided case is an example of the complexities with medication management to support the multitude of health conditions in an older patient while introducing polypharmacy and pharmacotherapy-related issues. NPs are practitioners engaged in direct patient care and are able to identify PIMs, re-evaluate prescribing practices, and ensure the safe use of medication therapy. Through the initial dialogue with a patient, an NP can obtain a complete up-to-date list of medications (prescription and nonprescription products) and identify the challenges with medication therapy (eg, adherence, insurance, pharmacy, and language), the current and preferred pharmacy, and the past medical history, among other relevant information (Table 3). The next step is to assess and evaluate for PIMs; the efficacy and tolerability of each medication; and opportunities to deprescribe and/or prescribe considering the patient’s current health status, response to therapy, and available practice guidelines. Deprescribing may be challenging, especially when the patient is under the care of other providers, considering the risk and benefits of therapy, time constraints, public perception of medication use, and the pressure to prescribe. This would be a great opportunity to collaborate with a pharmacist or other health care providers who can support the initiative to review, deprescribe and prescribe appropriate pharmacotherapy, and reduce inappropriate polypharmacy.
38
Table 3Essential Practitioner Questions: Evaluating the Safe Use of Pharmacotherapy
3
, 4
, 5
, 6
,22
, 23
, 24
, 25
, 26
, 27
, 28
, 29
, 30
, 31
, 32
, 33
, 34
, 35
, 36
, IBM Micromedex Healthcare Series [internet database]. Greenwood Village, CO: Thomson Healthcare. Update periodically.
https://www.micromedexsolutions.com/home/dispatch
Date accessed: October 6, 2019
37
|
Conclusion
As the number of older patients encountered in practice increase so does the complexities of their health management. Multiple comorbid disease conditions and polypharmacy naturally become prominent issues. Practitioners should continue to assess and re-evaluate patient medication regimens to minimize issues secondary to polypharmacy and optimize patient outcomes.
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- NKF and NSAID Alliance declares NSAID awareness week.https://www.kidney.org/news/nkf-and-nsaid-alliance-declares-nsaid-awareness-week-august-24-%E2%80%93-28Date accessed: June 28, 2019
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- How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.J Pain Symptom Manage. 2000; 19: 130-136
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Biography
Timothy Nguyen, PharmD, BCPS, CCP, FASCP, is a professor of pharmacy practice at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University in Brooklyn, NY, and can be contacted at [email protected]
Elaine Wong, PharmD, BCPS, BC-ADM, is an associate professor of pharmacy at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University.
Francesco Ciummo, PharmD, BCCCP, is an assistant professor of pharmacy practice at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University.
Article info
Publication history
Published online: January 05, 2020
Footnotes
In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
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© 2019 Elsevier Inc. All rights reserved.
