The People's Perspective on Medicine

Polypharmacy and Premature Deaths Especially in Older People

How many pills do you take each morning. Anything more than 2 or 3 means you are practicing polypharmacy. Multiple medicines could lead to a deadly mix.
Senior Man, arms crossed, looks down at large assortment of prescription bottles pills

Have you been to a doctor’s office or a clinic lately? Chances are very good that a med tech weighed you, measured your blood pressure and took your temperature. This information was entered into a computer. That person probably asked about the medicines you are taking and checked them off in your electronic medical record. This person is not trained to check for drug interactions. And busy doctors and nurses may not take a lot of time to review your medication list for incompatibilities. Even if you are taking a handful of medications and dietary supplements, such polypharmacy may be overlooked.

Our Love Affair with Drugs:

All you have to do is watch a few minutes of television to realize that Americans take an enormous number of medicines. Commercials promoting drugs for diabetes, ulcerative colitis, rheumatoid arthritis, psoriasis and fibromyalgia are commonplace. Such advertising is very expensive but it is obviously extremely effective.

Experts estimate that 4.25 billion prescriptions will be dispensed this year at retail pharmacies. Imagine that many of those amber bottles contain 30 or more pills.

That does not count the medicines administered in hospitals or retirement communities. It also ignores over-the-counter products and dietary supplements. This means that Americans likely swallow way more than 100 billion pills annually.

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We’ve done some crude back-of-the-envelope calculations. Not counting OTC products or dietary supplements, we estimate that each man, woman and child in the U.S. swallows over 388 pills every year. If you just count adults, it’s more like 500 pills a year. We suspect that is a very conservative estimate. We know that there are tens of millions of people who swallow a handful of pills every day!

The Polypharmacy Predicament:

The problem with this love affair with drugs is something called polypharmacy. That is the technical term for taking multiple medicines. Polypharmacy has become a huge public health problem.

The nonpartisan Lown Insitute has issued a report titled:

“Medication Overload: America’s Other Drug Problem.

How the drive to prescribe is harming older Americans.”

Here are some of the findings:

“Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events, and there were more than 2 million hospital admissions.”

Polypharmacy Outcomes

Did those numbers from the Lown Institute surprise you? Have we become so accustomed to adverse drug reactions that we just take such statistics for granted?

One of the contributors to so many drug complications is the epidemic of polypharmacy. The Lown report notes that:

“More than four in ten older adults take five or more prescription medications a day, an increase of 300 percent over the past two decades. Nearly 20 percent take ten drugs or more.”

When someone takes that many medicines simultaneously, there is a high probability for drug interactions.

Examples of Dangerous if Not Deadly Interactions:

Tens of millions of people take a category of medications for high blood pressure called ACE inhibitors. This includes drugs like benazepril, captopril, enalapril, fosinopril, lisinopril and ramipril.

Such medications interact very badly with a common antibiotic known as co-trimoxazole. The actual ingredients are trimethoprim plus sulfamethoxazole. This combo is often abbreviated as TMP-SMZ or TMP-SMX. You may recognize the brand names Bactrim or Septra. The sulfamethoxazole is a “sulfa” antibiotic.

You can learn more about the nature of this under-appreciated drug interaction at this link.

Medical Mistakes and Deadly Drug Interactions

More information about this and another potentially deadly interaction can be found here:

Blood Pressure Drug Combos That Could Be Lethal

Theory vs. Reality: Polypharmacy in the Real World:

Reading how polypharmacy can be problematic is important. But everything you read above is theoretical. It does not reveal the personal nature of such interactions.

Bill in Katy, Texas had been on an ACE inhibitor for two decades to treat high blood pressure. Then a urologist gave him Bactrim, presumably to treat a urinary tract infection. As mentioned, this combination has killed people:

“I was taking benazepril for twenty years with no problems. Then my urologist gave me a prescription for Bactrim. Not long after I fell down four times.

“I eventually made an appointment with my primary care physician. He was so concerned he personally drove me to a hospital. They kept me for five days. When I was released I had a neurological condition called foot drop. My gait was severely affected for several months.

“I still have difficulty with my balance, even after a lot of physical therapy. I believe the combination of Bactrim and lisinopril caused me harm.”

Erin in San Jose, California may have had a closer call than she realized:

“I had an unusual drug reaction that I am now wondering might have been due to an interaction. I was taking lisinopril for high blood pressure. Then I developed an infection and was given a sulfa drug. I developed horrible vertigo after drinking a cup of coffee.

“I felt so bad I told my husband to call 911. When the ambulance arrived, the medics didn’t seem all that concerned. Nevertheless, they did take me to the hospital. I began to get better shortly after. I’ll never know how close a call I had. Now I tell everyone I am allergic to sulfa drugs. That seemed to be the only thing that changed prior to the attack.”

Symptoms of Too Much Potassium (Hyperkalemia):

It is impossible to prove that Erin had an attack of hyperkalemia (excess potassium) in her body. That is what can happen after combining a medicine like Bactrim (a sulfa drug) with an ACE inhibitor such as lisinopril. When potassium levels get too high, symptoms can include irregular heart rhythms (arrhythmias), fatigue, weakness, an odd tingling feeling, nausea, paralysis and ultimately, cardiac arrest.

When someone dies while taking a dangerous drug combination the cause of death is rarely attributed to the medications.

Here is Janet’s story about her husband’s tragic death.

“My husband experienced cardiac arrest and died twenty days after being prescribed trimethoprim. He had been taking lisinopril to treat hypertension.

“When the doctors performed an autopsy, they concluded that the lining of two heart arteries had fatty deposits and that he had a heart attack. There was nothing in the death certificate about a possible drug interaction. My husband had no prior symptoms of heart trouble.”

Proving that Janet’s husband died from a deadly drug interaction would be hard under any conditions. Cardiac arrest from excessive levels of potassium would be difficult to distinguish from a heart attack. This is exactly the kind of suspicious death the authors of this article in the BMJ (Oct. 30, 2014) describe. 

Psych Drugs and Polypharmacy:

A report from the ISMP (Institute for Safe Medication Practices) QuarterWatch (March 27, 2019) analyzed FDA data regarding commonly prescribed pain medicines.

Gabapentin (Neurontin) or pregabalin (Lyrica) are taken by more than 10 million Americans. These drugs are referred to as GABA analogs because they mimic a brain chemical called gamma-aminobutyric acid (GABA).

According to the QuarterWatch report: 

“Nearly one-half of GABA analog patients were also taking 10 or more other drugs, increasing the risk of interactions, overdose or inhibiting effects on other needed drugs.”

Many of the people taking gabapentin or pregabalin were also taking opioid pain relievers, antidepressants, sleeping pills or anti-anxiety agents.

Polypharmacy: More Common Than You Imagine!

How does this happen? It’s easier than you might think. Gabapentin comes with a warning about psychological depression and/or suicidal thoughts or behaviors. In theory, patients who develop depression while taking gabapentin should be gradually phased off the drug. Instead, though, many appear to be put on antidepressant medications.

Some antidepressants such as bupropion, fluoxetine or sertraline can cause insomnia as a side effect. To solve that problem a doctor might prescribe a sleeping pill like zolpidem (Ambien). In almost the blink of an eye a patient suffering from nerve pain is on three different medications that all affect the brain and could lead to confusion, dizziness and memory impairment.

The Lown Institute concludes its report with a stern warning:

“If nothing is done to change current practices, medication overload will lead to the premature deaths of at least 150,000 older people in the U.S. over the next decade, and it will reduce the quality of life for millions more.”

Polypharmacy is NOT just an older person’s problem. Anyone taking a bunch of pills is vulnerable. A young woman taking a migraine medicine, an antidepressant, birth control pills and a diarrhea drug could just as easily get into trouble as a 74-year-old man taking medications for high cholesterol, hypertension and diabetes. 

To combat the problems of polypharmacy, physicians, pharmacists, patients and family members will need to be far more vigilant. We need to combat the message that “more is better.” Less may be best when it comes to drugs!

iMedical Consensus Advisory

Everyone agrees that polypharmacy and drug interactions are a huge public health problem. There is no consensus, however, about how to solve the problem. Many experts think that technology will be the answer. But even with electronic health records firmly in place the problem has only gotten worse. Deprescribing is a movement that is growing, but it has not yet been implemented in a systematic way. There is much yet to be done.

Protect yourself and those you love by reading the chapter “Drug Interactions Can be Deadly” in our book Top Screwups. We include detailed protective measures you can take with our “Top 11 Tips for Preventing Dangerous Drug Interactions.” Here is a link to our bookstore.

Share your own story about polypharmacy in the comment section below.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    Citations
    • “Medication Overload: America’s Other Drug Problem. How the drive to prescribe is harming older Americans.” The Lown Institute: https://lowninstitute.org
    • Fralick, M., et al., "Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study," BMJ, Oct. 30, 2014, doi: https://doi.org/10.1136/bmj.g6196
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    This polypharmacy theory is very scary. I do take more than 3 meds a day: Multi-vitamin, Norvasc, Losartin, Protonix, Fish Oil, Eloquis, Baby Aspirin, Magnesium, Potassium, and Flomax (every morning), and then I take Namenda, Luvox, Aricept, Eloquis, and Baby Aspirin (every night). I am 76 and fairly good health. I have tried to cut down on all, but my doctors say that I need them all to stay healthy. I pray there are no interactions. However, I do not take any of the drugs mentioned above. Your comments please.

    More information like this needs to be publicized. As I have noted before, it was difficult to see the deterioration of my husbands health as doctors prescribed one med after another. The final one, a strong potassium prescription caused some terrible events to come about. Wish I had researched the side effects of each drug before he passed away. I am not bitter, but wiser.

    I am 78 and have been taking more than three medications a day for at least ten years with no apparent ill effects. Most are indispensable. For example anastrozole for metastatic breast cancer (11 years); low dose Paxil for the hot flashes caused by anastrozole; thyroid medication (at least 15 years); bupropion for depression (20 years); trazodone for persistent insomnia. Two blood pressure meds (Irbesartan and lasix); Magnesium controls restless legs. Fish oil keeps my doctor happy with my cholesterol ratio. Various mushroom supplements for cancer. I also use Adair and a nebulizer for COPD, caused in part, by the cancer spreading to a lung.

    All that makes me sound like a basket case, even to me. Oddly enough, I feel pretty healthy except for being slowed down by age. I honestly don’t know what I could eliminate. Can you tell me?

    I have done the math twice, using a calculator. If you divide 4.25 billion (prescriptions) by 350 million, ( approx. US population) the answer is just over 12. That is 12 prescriptions per person. Given that most children and young adults take few if any prescriptions, I’d guess you could safely say that it equals at least 20 prescriptions per adult and that no doubt goes up the older the patient. That’s a whole lot of drugs ingested by a whole lot of people, (and a WHOLE lot of money), yet… the population is generally less healthy and the life expectancy is actually going down for younger people. I’m thinking we need a completely new paradigm of healthcare. Am I holding my breath??? NO!!

    Though I take only 4 basic prescriptions, an ARB, generic Plavix, generic Cardura, and generic Proscar, it has been my practice over many years to take the blood pressure and blood thinner meds at breakfast, generic Proscar at lunch time, and generic Cardura at bedtime because I had the sense that mixing the different meds might have some sort of interaction or canceling effect if taken at the same time. About two years ago, a nurse practitioner said that it was unnecessary to divide up the pill-taking routine in this fashion and that I should take them all at the same time. However, I continue taking the meds on my own schedule, as I still believe that it’s the better way to do the job with less chance of an interaction problem. It’s also easier for me to remember to sort and take the various pills in this established routine.

    Big Pharma has America right where it wants it. Thankfully at age 69, I take no medications and before I ever will (barring an emergency, perhaps), I will try to find more natural solutions to my problems. If vitamins and minerals are not important, especially as we age, they why eat any food? Why not just take a handful of pills and live happily ever after…at least according to the commercials which is one of the reasons I do not watch TV. Do I trust all those medications not to react with each other somehow? No way. I would bet that a lot of deaths are the result of drug screw-ups but we will never know the truth because on the death certificate, Big Pharma has all but banned the use of any wording that would suggest it is at fault.

    388 pills per year? Amateurs! I take 24 per day. Only 3 are prescription meds; the only one I worry about is Lisinopril…

    The biggest problem with meds in the USA is people not researching what they are taking and trusting their doctors too much. For me I am off ALL drugs and am 75 years old. How I did it was to go to a chiropractor and have my nervous system checked out, and it brought my blood pressure down so that I was able to wean off those bp meds. I then realized through research that the body is self-healing and self-regulating, and blood pressure normality does not exist at all.

    Great info on Polypharmacy! I’m epileptic and take 300mg of Dilantin every day. I have to be extremely careful because several drugs can cause Dilantin toxicity. A few years ago I had a cold and took Nyquil. The next day while walking the dog I fell and had absolutely no muscle control. I was wide awake but just couldn’t control my muscles. I recovered in just a few minutes but it was really scary. I recently moved to the Triangle area and have been diagnosed with Afib so am on blood thinners.

    I tried Eliquis for a while but after another muscle breakdown incident I’m now on Warfarin which is a pain, given routine INR test, but it works. Neurologist told me to stay away from antihistamines because they can cause the Dilantin toxicity. Don’t know why I had an Eliquis reaction but somehow it seems to interact with the Dilantin.

    The average life expectancy hasn’t risen appreciably in the past 2 decades, but the cost of “health care” has skyrocketed. Seems something must be very wrong here. No real good being done except to the bottom line. Lower for the patients and staggeringly higher for the medical machine.

    I recently was prescribed a Septra generic for a UTI. I have been taking Lisinopril for 10 years for blood pressure control. On the 6th day of taking this combination of medicines I was admitted to the ER for nausea and dehydration. Testing revealed that I had suffered a mild heart attack that I believe was a result of a drug interaction, since I have never been diagnosed with heart disease or high cholesterol. My potassium level was in the high normal level at 4.8. Since my potassium level was not excessively high, does that rule out the possibility of the drug interaction causing the heart attack?

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