INTRODUCTION:

Medications play a key role in the treatment and prevention of disease and reduce morbidity and mortality rates. There are a variety of medical conditions and diseases that cannot be controlled treated or prevented solely by the use of one medication. The use of more than one medication or a combination of drugs has shown great outcomes in the perspective of patients' health. These combinations should be according to acknowledged guidelines to ensure patients' health^1,2.

Polypharmacy is a term or description applied in the medical health care system to describe patients receiving more than one medication in order to treat their health problems and improve their quality of life³. The exact definition according to a standard medical dictionary is related to the word “poly” meaning more than one in the Greek language. The word pharmacy is related to the Greek word “pharmacon" which means drug. Polypharmacy is prescribed regardless of age, to clarify the statement polypharmacy is not only prescribed for the elderly patient it can be prescribed for any age group. With increased age, the possibility for the incidence of health problems especially chronic diseases like (hypertension, ischemic heart disease, renal failure…etc) will increase. Hence, the necessity of multipharmacotherapy will accordingly increase⁴.

For this reason, polypharmacy is more frequently prescribed for the elder patient compared to the younger patient population⁵. The use of polypharmacy has increased over the years due to reasons other than the prescriptions which licensed physicians prescribe, which is due to increased use of over-the-counter drugs without the consent of a physician. Polypharmacy can cause many complications, the most important drug-related problem that should be taken under consideration are drug-drug interactions this is one of the reasons the physician should always follow acknowledged guidelines, pharmacist has a crucial rule on this topic⁶.

Studies show that the use of 2 medications simultaneously, has a risk of drug-drug interaction of 13%, and if 4 medications the risk is 38%, and if 7 medications or more the risk will be increased up to 82%, so the increase in the number of medications used simultaneously or polypharmacy increases the possibility for drug-drug interactions¹. Many factors can attribute to polypharmacy like age, presence and number of comorbidities, number of prescribers and many other factors⁷. In some instances, polypharmacy is inevitable, in cases of life-threatening infectious diseases, such as COVID-19, in which cases anti-infective^8,9 and supportive drugs^10-15were used. In this study, we will focus on the prevalence of polypharmacy among local prescribing patterns and some of the factors related to it.

MATERIALS AND METHODS:

Study design: a prospective cross-sectional study.

Setting: The study was conducted at Azadi Hospital. It is the main governmental hospital in Duhok city in Kurdistan Region in the north of Iraq.

Selection criteria: All the elderly patients who are attending internal medicine wards at Azadi hospital and willing to participate in the study.

Statistical analysis: Data was collected, coded, tabulated and analyzed, using the Statistical Package for Social Sciences software IBM SPSS V. 22.0, 2013; IBM Corp., Armonk, New York, USA. To estimate the prevalence of polypharmacy, the frequency and proportion (%) were presented. The Chi-square test was used to investigate the factors associated with polypharmacy.

RESULT:

Table 1: Socio-demographic Characteristics

	Characteristics	n	%
BMI Category	Underweight	3	1.5
	Normal	93	46.5
	Over Weight	79	39.5
	Obese	22	11
	Very Obese	3	1.5
	Total	200	100%
Education Level	Illiterate	182	87.10%
	Primary School	8	3.80%
	Secondary School	5	2.40%
	University	5	2.40%
	Total	200	-100%
Age groups	65 - 74	113	56.50%
	75-85	69	34.50%
	85+	18	9.00%
	Total	200	100%

Figure 1: (A) Gender Distribution among patients. (B) Chronic PolyPharmacy Distribution across Gender. (C) Chronic Polypharmacy Prevalence. 27% (n= 53) of the elderly patients were receiving more than five medications. Only medications that were used for chronic disease were counted. (D) Prevalence of Polypharmacy among age groups. The highest prevalence is among patients aged 65 to 74 years.

Table 2: Results of Chi-square test

Risk factors	Pearson Chi-square Value	P
Diabetes Mellitus	6.76	0.009
Heart Diseases	5.58	0.018
Renal disease	3.26	0.057
Hypertension	2.12	0.052
Age	4.65	0.03
Low education level	1.63	0.19
Obesity	6.4	0.32

Figure 2: (A) Comorbidities number among the hospitalized elderly population. The majority were having at least two diseases. (B)Type of comorbidities among the selected elderly patients. Heart diseases are the most common to be followed by hypertension and diabetes subsequently. (C) Medication Type according to ATS.

Diabetes mellitus has shown the highest association with polypharmacy compared to the other factors. The Chi-square test result for this risk factor is χ2 = 6.76., df = 1, p < 0.05. To be followed by heart diseases, and age. Other factors have no association with polypharmacy according to our current study results.

DISCUSSION:

The female was slightly more than the males in this study as shown in figure 1, (54%, n=107). This is unlike a similar study in UAE where males were more than female¹⁶. In our study, the prevalence of polypharmacy in males and female were 25% and 28% respectively. Unlike other studies (28,32), there was no big difference in the prevalence of polypharmacy due to gender differences. Only 11% (n= 22) of the selected patients were having obesity with 39.5% (n=46) having normal body weight. The most interesting finding in the demographics data is the noticeable high percentage of illiteracy among the study population (87%, n=182).

The use of multiple drugs concurrently by elderly patients is a very common issue in the population which might be accompanied by many health problems and may even exacerbate their conditions as explained earlier in the introduction of this research. In our research we depended on the definition of polypharmacy to be the use of five medications and more, the 5 medication threshold derives its justification from the linear growth of adverse effects the higher the number of medications^17-20., if they are used for a short duration we considered it as "acute polypharmacy", and if multi medication is used for a longer duration, we called it "chronic polypharmacy " or continuous polypharmacy, which was we primarily focused on due to many reasons since using more than 5 medications for chronic use is more likely to be associated with drug-drug interactions, drug-disease interactions, adverse reactions of drugs, decrease compliance, increase the risk for drug misuse, reduce the quality of life, increase hospital admissions and causing extra costs. This approach will more accurately account for the treatment of long-term conditions and reduce the number of drugs prescribed to treat acute illnesses and medications taken infrequently or irregularly.

Assessing the psychotherapeutic and financial implications of a serious illness on a person will be made simpler with the aid of constant or chronic polypharmacy. Only pharmaceuticals taken consistently over time will be seen to be of utmost importance; concurrent illnesses and short-term treatments will no more be taken into consideration. According to our research findings, the prevalence of continuous polypharmacy (polypharmacy of chronic diseases) was 27% (n=54) among the selected study population. Unfortunately, the exact impact and evaluation of this finding may be difficult owing to the limited number of related studies to measure the prevalence of polypharmacy on chronic diseases at the national and international levels. Instead, most of the previous studies focus on measuring what's called one-day prevalence or acute polypharmacy. In one study by Beuscart et al. (2014) using information from the Nord-Pasde-Calais region of French health insurance, it was predicted that 35% of people over the age of 75 had received more than 10 prescriptions over the three months of the study, with a median of 8.3 drugs²¹. However, the threshold used in this study is not the same as we used (10 medications in the French study versus 5 medications in our current study) which render the comparison not accurate. The most appropriate study for comparison is the Italian study done in the year 2010 which was also setting 5 or more medications as the threshold for chronic polypharmacy. The prevalence of chronic polypharmacy was lower (20%) than in our study²².

The number of morbidities for each patient was also counted in this study. 42% of the study population (n=84) have 2 chronic diseases. About 22% (n=45) had 3 diseases and 7% (n=14) had four diseases while only one patient have five diseases (figure 2). The most common disease among the study population are heart diseases (n=128, 64%), to be followed by hypertension (n=118, 59% ) and diabetes mellitus (70, 35%). Drugs of the cardiovascular system also were the most common among other medication types, to be followed by alimentary tract and blood-forming medications.

In earlier studies^23–25, the top three pharmaceutical groups most frequently provided to the geriatric were cardiovascular, central nervous system, and gastrointestinal medicines. Except for medications targeting the CNS, our investigation produced identical results. In terms of the most prevalent medicine type, the findings of our study are only comparable to those of an Italian study²².

The factors that have been tested in this study for association with polypharmacy are shown in table 2. The data about risk factors were given as yes/no. The results of analysis reveals that the higher association seen where with diabetes mellitus with χ² = 6.76, df = 1, p < 0.05 followed by heart diseases χ² = 6.16, df = 1, p < 0.05 and age χ² = 4.65, df = 1, p < 0.05, whereas the remaining factors show no significant association at p > 0.05.

CONCLUSION:

The findings of this study show that exposure to chronic medications and chronic polypharmacy are substantially correlated with age and morbidities as important determinants of drug administration. All hospitals should design a strategy or care plan to reduce the amount of polypharmacy that older patients are exposed to. The groups that are most susceptible to polypharmacy should be the focus of efforts to reduce difficulties related to it. Our study's findings indicate that older persons and those using medication for diabetes, kidney illness, or cardiovascular disease should receive top priority.

REFERENCES:

1. Jyothi PD, Swetha K, Samatha S, Sree GS. A study on evaluation of prescribing pattern in diabetic patients at tertiary care Hospital. Research Journal of Pharmacy and Technology. 2020;13(12):5881-4.

2. Das SK, Shenoy S, Varma M, Rajesh R, Shankar R, Holla S, Saravu K. A Study of Potential drug-drug interactions in HIV positive individuals with Co-morbidities. Research Journal of Pharmacy and Technology. 2022 May 30;15(5):1960-6.

3. Sembian N. Polypharmacy and its Management. Research Journal of Pharmacy and Technology. 2014 Mar 1;7(3):5.

4. Lincy S, Greeshma M, Maheswari E, Tharanath S, Viswam S. An Empirical Study to assess the Pattern and Predictors of Adverse Drug Reactions associated with Polypharmacy in the Department of General Medicine. Age. 2018 Nov 30;75:50.

5. Siddiqua A, Abdullah RK, Kareem NA. Impact of Clinical Pharmacist Intervention towards Polypharmacy in Elderly population-A Systematic Study. Research J. Pharm. and Tech. 2019 Jun 30;12(6):2621-7.

6. Vinod K Mathew, Kishore Gnana Sam, Beulah Milton, Amit Kumar Das. Prescription Pattern of Antipsychotics Polypharmacy in patients with Schizophrenia in an Indian Hospital. Research Journal of Pharmacy and Technology. 2021; 14(8):4265-9.

7. Manjula S., Nalini Jeyavanth Santha. Expressive Therapy for Geriatrics. Int. J. Adv. Nur. Management 2(1):Jan. - Mar., 2014; Page 31-33.

8. Darweesh O, Abdulrazzaq GM, Al-Zidan RN, Bebane P, Merkhan M, Aldabbagh R, AlOmari N. Evaluation of the Pharmacologic Treatment of COVID-19 Pandemic in Iraq. Current Pharmacology Reports. 2021 Sep;7(4):171-8.

9. Zainal AA, Merkhan MM. Impact of antidiabetic drugs on risk and outcome of covid-19 infection: a review. MMSL. 2022 Jun 3;91(2):140-60.

10. Merkhan MM, Abdullah KS. The role of vitamin C and E in improving hearing loss in patients with type 2 diabetes. Annals of the College of Medicine, Mosul. 2020 Jan 29;41(2):184-9.

11. Althanoon ZA, Merkhan MM. Effects of zinc supplementation on metabolic status in patients with metabolic syndrome. Acta Poloniae Pharmaceutica. 2021 Jul 1;78(4):521-6.

12. Younis HY, Imad A. Effect of zinc as an add on to metformin therapy on serum lipid profile and uric acid in type 2 diabetes mellitus patients. Curr topics in Pharmacology. 2021;25.

13. Younis HY, Thanoon IA, Fadhil NN, Merkhan MM. Effect of Zinc as an Add-On to Metformin Therapy on Glycemic control, Serum Insulin, and C-peptide Levels and Insulin Resistance in Type 2 Diabetes Mellitus Patient. Research Journal of Pharmacy and Technology. 2022 Mar 24;15(3):1184-8.

14. Almukhtar HM, Faisal IM, Merkhan MM. Short-term treatment with Atorvastatin selectively decreases Lymphocyte count. Research Journal of Pharmacy and Technology. 2022 Feb 1;15(2):689-94.

15. Merkhan MM, Abdullah E, Althanoon Z. Effect of Esomeprazole on serum creatinine and urea in patients with Peptic Ulcer. Research Journal of Pharmacy and Technology. 2022;15(1):160-4.

16. Al Ameri MN, Makramalla E, Albur U, Kumar A, Rao P. Prevalence of polypharmacy in the elderly: Implications of age, gender, comorbidities and drug interactions. J Pharm Pharm Sci. 2014;1:1-7.

17. Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J. The influence of educational level on polypharmacy and inappropriate drug use: a register‐based study of more than 600,000 older people. Journal of the American Geriatrics Society. 2009 Jan;57(1):62-9.

18. Hovstadius B, Åstrand B, Petersson G. Dispensed drugs and multiple medications in the Swedish population: an individual-based register study. BMC clinical pharmacology. 2009 Dec;9(1):1-0.

19. Grimmsmann T, Himmel W. Polypharmacy in primary care practices: an analysis using a large health insurance database. Pharmacoepidemiology and drug safety. 2009 Dec;18(12):1206-13.

20. Jyrkkä J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Patterns of drug use and factors associated with polypharmacy and excessive polypharmacy in elderly persons. Drugs & aging. 2009 Jun;26(6):493-503.

21. Beuscart JB, Dupont C, Defebvre MM, Puisieux F. Potentially inappropriate medications (PIMs) and anticholinergic levels in the elderly: a population based study in a French region. Archives of gerontology and geriatrics. 2014 Nov 1;59(3):630-5.

22. Nobili A, Franchi C, Pasina L, Tettamanti M, Baviera M, Monesi L, Roncaglioni C, Riva E, Lucca U, Bortolotti A, Fortino I. Drug utilization and polypharmacy in an Italian elderly population: the EPIFARM‐elderly project. Pharmacoepidemiology and drug safety. 2011 May;20(5):488-96.

23. Jensen E, Schroll M. A 30-year survey of drug use in the 1914 birth cohort in Glostrup County, Denmark: 1964–1994. Aging clinical and experimental research. 2008 Apr;20(2):145-52.

24. Jörgensen T, Johansson S, Kennerfalk A, Wallander MA, Svärdsudd K. Prescription drug use, diagnoses, and healthcare utilization among the elderly. Annals of Pharmacotherapy. 2001 Sep;35(9):1004-9.

25. Barat I, Andreasen F, Damsgaard EM. The consumption of drugs by 75-year-old individuals living in their own homes. European journal of clinical pharmacology. 2000 Sep;56(6):501-9.

Received on 31.08.2022 Modified on 17.10.2022

Research J. Pharm. and Tech 2023; 16(6):2627-2630.

DOI: 10.52711/0974-360X.2023.00431