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Polypill (good) or polypharmacy (bad) — discuss
By Admin Editor
I don’t know about you, but I’m getting confused about the difference between polypharmacy —traditionally bad — and a polypill — which seems to be increasingly discussed in positive terms and which we report again this week.
I suppose what I’m trying to work out is whether the so-called polypill is to be used for the benefit of individual patients or will be used to treat entire populations regardless of individual clinical needs.
Call me an old-fashioned libertarian, but I believe that people should be allowed to make their own choices about whether or not they want to be treated, with the sole exception of people who clearly lack the mental capacity to do so. But that is a whole different can of worms that I don’t want to open here.
It’s a real ethical dilemma, isn’t it? Treating people or populations, I mean. Should we fluoridate water to reduce dental caries? On balance, I think yes. Should we impose combination vaccines and make it impossible for people to choose single vaccinations? On balance, I think not.
But that’s where the problem lies — in the balance.
Where do you draw the line? And that's a genuine question, so feel free to let us know your views using the comment form below.
Michael Thompson
Editor, PJ Online
A surfeit of Polys
I would slate the polypill without hesitation - five components, How do we know how they are acting when placed together; the various componants are all worthy drugs with well recorded actions in lowering cardio vascular risk, but placed together... In my earlier days, I recall when the first combination drugs came onto the market, Beta-Adalat, Co-tenidone etc. The BNF of the day said that these combinations were unwise as patients might need a dose outside the fixed combination of the medicament. With two drugs combined, you might stand a chance , with five drugs, who knows how the various drugs interact? A point often missed by pharmacists, is that drugs act at a molecular level on specfically shaped receptors, and subtle changes to molecular shape can have profound effects on the body. ( eg Zantac is the pure L isomer of ranitidine, generic ranitidine is the racemate - how many patients have said they prefer Zantac to generic, because it works better?) Having five drugs in combination, beggars belief.How do we know that one two or three or even four or five of these individual drugs are not forming compounds that are acting in a way out of proportion to their components, such as the combination of cocaine and alcohol? OK the Lancet study found some evidence of effect, but at what cost? I would say that this approach is the "scatter gun" of pharmacology - if you fire enough drugs at a problem, then one of them is bound to stick, but which one, and is that one acting on it's own or in concert with another molecule - what are the long term effects?
Polypharmacy - I give up!! Every day in every pharmacy we see Rxs for unwise combinations of drugs, drugs that are doing the same job, but repeated in multi-item Rxs. If you counsel the patient, often comes back the rejoinder "Well my doctor gave them to me" or "Well I would rather go with the doctor - you're not a doctor!!" After a few of these exchanges, one gets mightily "dischuffed"
The MUR was going to be the great hope for the future of pharmacy, we were going to be seen as the clinicians we are at last. If MURs were performed in an accurate way, then the 20 item Rx with at least three interactions would have been a thing of the past. But MURs are NOT weeding out these anomalies - we laud pharmacists who get their quota of 400 MURs, and we say "What a good fellow", but what impact does this level of activity have on the 20 item Rx? It's still there, people are still getting more ill from polypharmacy, because the patient believes it their right to have as many drugs as will fit on as many Rx forms ("I've paid my contribution to the 'elf service, now I want my medicine!"), and from GPs who see this tinkering around the edges, as another encroachment onto their monopoly.
I would rather do 4 MURs a year of intensive worth, which helped a patient get better health, than the 400 that some pharmacists and ALL multiples see as the Holy Grail of pharmacy practice which in the end benefit the patient not one iota, because they are a production line in pharmacy practice, with the "mighty dollar" as the end point, not patient health.
In the meantime, the poor (????) old patient suffers from a surfeit of polys, and our taxes go up to fund it.
Regards
Bob Dunkley