The Virtues of Oligopharmacy

             

“Let food be thy medicine and medicine be thy food.”

                                                                                       Hippocrates

“I saw few die of hunger; of eating, a hundred thousand.”

                                                                                      Benjamin Franklin

“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”

                                                                                       Sir William Osler

The US Pharmacopeia is a tempting smörgåsbord of medications for every conceivable disease, ailment and risk factor. It can be approached either as a well-stocked holiday table for careful sampling or as an all-you-can-eat affair. Too much of anything can be deleterious to our health.

At a Swedish smörgåsbord, you typically don’t try to eat everything offered, and you avoid putting too many different things on your plate at the same time. On formal occasions you make several trips to the buffet table and use a clean plate each time. The smörgåsbord is just like a multi-course dinner with a choice of self-serve selections for each course. Etiquette suggests that the first plate includes your choice of pickled herrings and sharp cheeses, the second plate your choice of smoked salmon and other cold fish dishes, the third one cold meats and sausages, the fourth one warm dishes and the fifth one cheeses or sweet desserts.

Polypharmacy has become a buzzword in recent years. Most dictionaries have two definitions of the word, one neutral and one derogatory. The word can simply mean administration of a large number of medications, or it can imply administration of unnecessary medications.

A patient with several chronic conditions may end up taking a large number of perfectly appropriate medications. Even such “appropriate” polypharmacy can cause problems, particularly in the elderly, who are more prone to suffer medication side effects. Also, our understanding of drug metabolism and drug-drug interactions continues to evolve. For example, just within the past few months there have been new warnings about interactions between decades-old medications like simvastatin and amlodipine.

A recent example of how prescribing multiple medications can be fraught with problems is combination therapy for lipid disorders. Well-meaning doctors have combined statins with fibrates and even niacin in order to make each measurement in their patients’ lipid profiles normal. To this day there is no evidence that anything added to a statin regimen further decreases risk, even if a patient’s triglycerides and HDL are off the chart, including several studies published in the last 18 months.

No prescriber thinks they are prescribing too many medications. Since there is disagreement over exactly what number of medications constitutes polypharmacy, and since the word has become so derogatory, I suggest we instead speak of what we should strive for.

I suggest we use the term OLIGOPHARMACY to mean the administration of as few medications as possible to achieve our therapeutic goal.

Just the way a Swede may choose only one or two flavors of pickled herring for his first course at the smörgåsbord and leave some room for the next several courses, physicians may want to choose only a few of the best evidenced drugs for each of their complex patients’ primary diseases in order to also leave room to treat their multiple other medical conditions.

Years ago, I read an article, written in jest, suggesting that a fistful of medications, each with a certain proven percentage of risk reduction, could eliminate heart disease completely. Even when there is statistical evidence that a number of different medications can decrease risk or improve outcomes, we cannot assume their effects are multiplicative or even additive; sometimes all they do is increase the risk of side effects.

Let us think and act like polite Swedes at the smörgåsbord. Pick and choose among the favorites. Let’s not overindulge.