Polypharmacy is the curse of Modern Medicine- Dr. Fraz Mir


 AZMC and RCP Int. Medical Conference proceedings

Polypharmacy is the curse of
Modern Medicine - Dr. Fraz Mir

It is better to consult pharmacist, prescribe few drugs and
use long acting formulations while treating elderly patients

LAHORE: On Day three of the International Medical Conference organized by Azra Naheed Medical College in collaboration with Royal College of Physicians London, Dr. Peter Trewby spoke on ethical dilemmas in medicine. He pointed out that in medicine ethical principles provides a framework to help us make difficult clinical decisions. He then mentioned the four well known principles of medical ethics i.e. Autonomy, Justice, (to manage the patients in relation to others)Beneficence (to preserve life, restore health and relieve suffering or do well) and Non-maleficence i.e. Avoid harm. Justice has got to be distributive, rights based and legal which means better health for all, my patients vs. all patients, and wealthy patients vs. poor patients, national or global.

Continuing Dr. Peter said that whenever we do something good, we risk harming hence we need to know the balance of risk and harm so as to inform the patients. As such education of not only the patient but ourselves is also important. To inform the patient we must know the ratio of harm to benefit. He then gave the example of Fibrinolytic therapy for acute stroke and said that it results in 13% increase in rate of full recovery at three months.  But there is no difference in mortality at three months. Hence, we have no way of knowing who will and who will not benefit. However, the 13% overall benefit comes at the expense of a 6% increase in intracranial haemorrhage and an excess mortality of 3% at 36 hours. Ethical principles, he said, can be a useful signpost to guide our behaviour.  We should be aware of the often deeply conflicting messages that result from our attempts to apply them. Finally we must be adequately informed so as to inform our patients with regard to the potential harm to the individual arising from our wish to benefit the population, he remarked. He also discussed whether assisted suicide should be legalized or is it ethical to sell kidney? Those who favour assisted suicide for the terminally ill feel that palliative care may relieve physical sufferings but not psychological suffering. Similarly those who support the sale of kidney say that true autonomy of the donor and recipient is respected hence there is net benefit over harm for seller and the recipient.  However, those who oppose say that it involves financial exploitation and post-operative harm to poor donors. It also leads to reduction in volunteer donors, spread of HIV and there are many cultural issues as well.

Prof. M. Akbar Chaudhry talked about education of doctors of the future while Mr. Shaukat Ali Jawaid Chief Editor Pakistan Journal of Medical Sciences discussed the Medical Editor’s role in improving patient care and highlighted the story of the start of diabetic foot care in Pakistan by BIDE. Dr. Tanzeem Raza’s presentation was on Medical Professionals in the 21st century while Dr. Masood Jawaid Project Director Digital CME at UHS highlighted its aims and objectives besides demonstrating this project which will provide CME to healthcare professionals sitting at home. Those who secure pass marks will also get a certificate. Sania Nishtar talked about Medial Research in developing countries. Dr. Zahid Latif spoke about specialty preferences of medical students at Azra Naheed Medical   College, Lahore.

In the second session Dr. Fraz Mir from UK talked about Polypharmacy in the elderly. He pointed out that this tends to affect those with multiple co-morbidities because of un-necessary and excessive medications. At the same time one should not forget that some of these patients may also be taking herbal medications at the same time. Polypharmacy Dr. Fraz Mir opined is a curse of modern medicine. It is associated with increased adverse outcomes. Almost 40% of adverse events are preventable. It also leads to drug interactions, prescribing errors, poor compliance, more hospital admissions, readmissions and also increased mortality. He then quoted two studies from Pakistan which showed that Polypharmacy was seen in 70% of prescriptions in one study while in the other study no prescription had all essential components. Average number of drugs per prescription was 3.32, legibility was poor and only 10.2% prescriptions used generic names. Elderly people, he further stated, are more sensitive to the effects of drugs especially those acting on the nervous system. He also cautioned the audience to beware of headline grabbing and media distortions. His suggestion was to weight up risks vs. benefits which are of course very tricky. One must involve the patients if possible, pharmacist can help. Keep prescription to the minimum, use long acting formulations besides considering non-pharmacological treatments. He concluded his presentation by quoting Voltaire who had said “Doctors put drugs of which they know little into bodies of which they know less for diseases of which they know nothing at all.”

Dr. Asif Abbas Naqvi’s presentation was on management of refractory ascites. He pointed out that 75% of ascites is due to cirrhosis. Diuretics plus low sodium diet is effective in about 90% of patients. Speaking about clinical implications of Refractory Ascites he mentioned dilutional hyponatremai, Hepatorenal syndrome, spontaneous bacterial peritonitis, hepatic hydrothorax, spontaneous bacterial empyema and umbilical hernia.  It is important to ensure compliance with low sodium diet. During evaluation one must confirm low urinary sodium on diuretics at maximum dose. Treatment consists of large volume paracentesis, TIPs, Liver transplantation, Peritoneo-venous shunt, Alfa Pump and Pleurx drain. TIPS are effective in 30-90% of patients. Diuretics are still necessary in most patients and it takes one to three months for the ascites to resolve.  It may also improve renal function besides improvement of quality of life due to reduced abdominal volume. TIPS significantly improves LFT survival, liver disease related death, recurrence of ascites and Hepatorenal syndrome  but it also increases  the risk of post TIPS hepatic encephalopathy in  30% of cases.

Continuing Dr.Asif Abbas Naqvi said that all patients with refractory ascites should be considered for liver transplantation. It has over 90% survival for twelve months. Ascites could also take up to six months to resolve and long term five years survival is less than 70%. His conclusions were that refractory ascites has a 50% annual mortality. Low sodium is critical first step combined with diuretics. TIPS are effective in most but can cause PSE. If the patient is not a candidate for liver transplant, one should shift the emphasis to symptom control.

Prof. Rezvi Sheriff from Sri Lanka made a presentation on CKD of uncertain origin. Speaking about the characteristics of CKE in Sri Lanka, he said that our patients are young male farmers. They use and spray multiple pesticides often without proper personal protective equipment.  Use of cheap fertilizer is common which is contaminated with multiple heavy metals.  They use drinking water from the same farming area; eat rice and vegetable produces in the same area. They are malnourished or under nourished.  There were no reported cases of Sri Lankan Nephropathy prior to mid-1990s. The disease is confined and overwhelming patients are reported from paddy farmers in the dry zone of Sri Lanka. He then gave details of heavy metal and radioactive substances in fertilizers which have adverse effects. His conclusions were that water and fluoride hard water are the main players.  Heavy metals include cadmium, Arsenic, Selenium, Pesticides residue, Glyphosate, clinical dehydration, fructose containing drinks besides genetic factors were also responsible for the present state of affairs.

Dr. Nazir Malik talked about epilepsy while Dr. Qazi Zaman discussed Acute Medicine. Defining acute medicine, he stated that it is that part of internal medicine which is concerned with immediate and early specialist management of adult patients with a wide range of medical conditions who present in hospital as emergency. Urgent, by the right person in the right setting at the right time and first time were mentioned as the general principles of care. An acute medicine specialist should be able to cope high pressure environment, have exemplary time management skills, teaching expertise and must possess good diagnostic skills, he remarked.