Avoiding polypharmacy helps reduce heart failure exacerbations

By Will Boggs MD

NEW YORK (Reuters Health) - Scores of drugs and herbs can cause or exacerbate heart failure, so physicians must strive to reduce polypharmacy in patients at risk, according to a new scientific statement from the American Heart Association (AHA).

"Heart failure is a complex syndrome to both manage and treat," Dr. Robert L. Page II from University of Colorado School of Pharmacy, who co-chaired the writing group, told Reuters Health by email. "This clinical science statement provides an evidence-based reference for medications that can cause or exacerbate heart failure which crosses all major therapeutic domains and provides suggestions to minimize polypharmacy. However, it is important to realize that this list is dynamic in that new medications enter the market daily and recommendations may suddenly change."

Heart failure patients take an average of 6.8 prescription medications daily, and one study indicated that 88% of heart failure patients use over-the-counter (OTC) medications, 34.8% take herbal supplements, and 65.2% take vitamins.

"Data have shown that when a patient takes at least four medications, the risk for a drug-drug interaction increases to 38%; this number increases to 82% when patients are taking seven or more medications, which many patients with heart failure do," Dr. Page said.

He continued, "With these aspects in mind, our committee felt compelled to provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications which could exacerbate or cause heart failure."

In the first statement of its kind, AHA provides a comprehensive list of medications and complementary and alternative medicine (CAM) products that have been associated with heart failure or its exacerbation.

The recommendations, released July 11 by the journal Circulation, emphasize, above all, the steps physicians can take to minimize polypharmacy and thereby improve drug safety.

Healthcare providers should conduct comprehensive reviews of medication at each clinical visit and with each hospital admission.

Before new medications are added, providers should evaluate their potential risks and benefits. And as for existing medications, it's reasonable to discontinue those for which there is no indication and those that are contraindicated for a particular patient.

Combination medicines should be used where possible and affordable to reduce the number of medications taken daily, and it makes sense to avoid prescribing new medications to treat side effects of existing medications.

The recommendations support a team management approach in which one healthcare provider acts as "captain" of the medications, and patients are instructed to notify this individual whenever medication is changed or added to the medication list (preferably before that prescription is filled).

"When new medications are added or current medications stopped, open communication needs to occur between the patient's primary care provider and other specialists; between the provider and the health care team when questions should arise regarding the potential for a medication to exacerbate or cause for heart failure; and between patient and provider regarding medication management," Dr. Page said.

"Health care providers need to encourage patients to be actively engaged in their medication management," Dr. Page concluded. "This means educating patients on how to read OTC medication labels for sodium content and active ingredients of the product (e.g., ibuprofen, pseudoephedrine, etc.); having patients keep a current medication list; encouraging patients to be open and transparent regarding consumption of OTC or herbal medications; and educating patients on the indications/benefits of their medications as well as the OTC/herbal medications they should avoid."

Dr. Kumar Dharmarajan from Yale University School of Medicine, New Haven, Connecticut recently reviewed multi-morbidity in older adults with heart failure. He told Reuters Health by email, "Patients with heart failure almost always have multiple chronic conditions and a high risk of drug-related adverse events. Wherever possible, physicians should de-escalate medical therapy and choose non-pharmacologic treatments to reduce the risk of adverse events."

Dr. Felix Yam from UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California told Reuters Health by email, "Oftentimes heart failure exacerbations are attributed to disease progression, dietary indiscretion or medication non-adherence. It is important not to overlook the potential of drugs in precipitating heart failure. Enlisting the help of pharmacists and other healthcare providers using a team approach can increase the likelihood of detecting drug-related problems."

Dr. Ingrid Hopper from Monash University, Melbourne, Victoria, Australia told Reuters Health, also by email, "This is the first time the AHA issued a consensus statement on this topic. With the increasing prevalence of heart failure, it is important that internists are aware of the potential for drugs to impact on heart failure, even after a period of stability on the drug."

"Drugs should always be in the differential diagnosis of decompensated heart failure," she said. "It's important to focus on the common drugs, like NSAIDs which patients may not even remember they have taken. Antihypertensives, antidepressants, and pulmonary medications frequently end up on medication lists."


Circulation 2016.

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