Medication Management in Patients with Polypharmacy

Rehabilitation patients have complex conditions often requiring multiple medications. The term "polypharmacy" represents a well-known risk for those taking multiple medications. Polypharmacy, however, is more than duplications, overuse, or insufficient doses. In fact, there are over 130 published definitions of polypharmacy, as identified by Masnoon et al. (2017). Generally, the concept means taking five or more medications; however, such a definition does not take into account comorbidities and the safety and efficacy of drug combinations. The following is a case study that exemplifies the need to review medication lists beyond drug numbers and dosages. In addition, medications to help one condition can be contraindicated for treating another health issue. Evidence-based (and commonsense) practice requires comparisons and follow-up to identify inconsistencies, contraindications, and even the need for additional medications. Ironically, even more "polypharmacy" may be indicated when there are comorbidities. Usually, nurses perform medication reviews at every appointment, admission, or home visit. Beyond medication safety concerns, rehab nurses, in particular, recognize how quality of life can be compromised when medication problems exist.

Case Study

Brian is a 70-year-old man with Type 2 diabetes, first-degree heart block (prolonged PR segment and occasional tachycardia), and a newer diagnosis of myasthenia gravis (MG) with sudden double vision. MG is "an autoimmune disorder affecting the myoneural junction...[often with] initial manifestations [that] involve the ocular muscle" (Hinkle & Cheever, 2018, p. 2079). Per protocol, Brian was placed on pyridostigmine (Mestinon). His symptoms did not improve; he continued to have diplopia and developed ptosis. He was eventually started on prednisone, which ultimately resolved his double vision and drooping eyelid. Not surprisingly, the prednisone raised his glucose, thus requiring an increase to the maximum dose of metformin and the start of glipizide that was later advanced to its maximum dose. Brian was taking metoprolol for his heart block.