ART OF

POLYPHARMACY
ART OF POLYPHARMACY
• Term “ Polypharmacy” usually has a negative connotation; denotes use of non
essential, duplicative or ineffective medications
• However, a purposeful, scientific and well balanced multi drug regimens, when
planned and delivered well, can reap more benefits than harm
• Practising polypharmacy is difficult to avoid absolutely; but should be practised in
a scientific, evidence based, rational manner!
 CREATIVE
PSYCHOPHARMACOTHERAPY
CREATIVE
PSYCHOPHARMACOTHERAPY
• Sometimes combination therapies reflect wise, thoughtful and even elegant
amalgams, crafted with careful deliberation
• Capitalize on pharmacodynamic synergies, and complementary, non redundant
mechanisms of action
• Well devised multidrug plan, each component carefully suited for patient, based
on symptom profile, propensity for side effects, comorbid psychiatric or medical
comorbidities
• Minimised harm, maximized benefits.
WHAT IT IS..
• Scientific and evidence-based practice and theory with transdisciplinary approach
• Based on creative, positive, rational and critical thinking, with idiographic and
nomothetic knowledge
• Meaning and context-associated practice
• Art of healing based on science, experience and relationship
• Part of the patient's creativity-enhancing treatment; transculturally sensitive practice
• Personalized practice, based on shared decision making; Individualized and patient
preference respecting practice
• Quality of life, patients satisfaction and personal recovery focused practice
• Integrative and holistic practice
WHAT IT ISN’T..
• Not quackery practice
• Not anthithesis to modern or postmodern psychiatry
• Not dogmatic and authoritarian practice
• Not irrational OR random polypharmacy
• Not impersonal and only technical practice
• Not fragmented care/treatment
• Not marketing based practice
• Not adversity increasing polypragmasia
• Not harmful, toxic or nocebo increasing practice
 ART OF
DEPRESCRIBING
PHARMACOLOGICAL HYGIENE: THE ART OF
DEPRESCRIBING
• DEPRESCRIBING : Defined as the systematic process of identifying and reducing
or discontinuing drugs in instances in which existing or potential harms outweigh
existing or potential benefits, taking into account the patient’s medical status,
current level of functioning, and values and preferences
• End goal is not necessarily the complete cessation of medications but rather their
parsimonious use.
FACTORS AGAINST DEPRESCRIBING
Misperception that patient’s clinical status is better than it actually is
1
2 Habit of renewing prescriptions in perfunctory fashion e.g. without asking adverse effects,
lack of benefits

3 Lack of knowledge about actual effect of prev. introduced drug (e.g. Mood stabilizer
introduced by prev psychiatrist i/v/o BPAD contd indefinitely because patient seems stable.)

Incorrect diagnosis
4
5 Hope that additive effect might show greater benefit in the future

6 Speculative ideas about harm reduction (better to leave the patient on BZDs,
if stopped he might start using alcohol)
BASICS OF Acknowledge, discuss and
DEPRESCRIBING choose a right time for
deprescribing
#Avoid acute phase of illness
#Ensure compliance

Monitor and adapt Document a list of all

medications
#treat discontinuation
#current therapeutic and adverse
syndrome; abort or defer effects, potential drug
deprescribing if necessary interactions and risk benefit ratio

Identify which medication

Deconstruct one variable
at a time
#favour slow taper and cross
titrations to identify clinical
deteriorations early
would be most
appropriate for taper
#ensure adequate trial or
insurmountable intolerance before
relegating a drug to the garbage heap!!!
 PHARMACOLOGICAL PARSIMONY
• Capitalizing on use of one drug for many effects with
multiple receptor actions.
• Single drug for more than one useful purposes.
• Simplified drug regimens, improved efficiency.
• Evidence based practice with scientific know how of
drugs being used!
 RATIONAL
POLYPHARMACY
RATIONAL POLYPHARMACY
Treat two
pathophysiologically distinct
comorbid illnesses. e.g.
Epilepsy and Psychosis
Provide acute amelioration
Treat adverse effect while waiting for primary
produced by primary drug drug to act
e.g. antipsychotic induced e.g. BZD before
akathisia antidepressant to relieve
insomnia

Boost or augment primary

Treat intervening phase of an
treatment
illness
e.g. lithium, thyroxine,
e.g. post schizophrenic
modafinil to augment
depression
antidepressant therapy.
Rational Prescribing: SAIL Approach
• Keep drug regimen Simple
S
• Know Adverse effects
A
• Must have clear Indications
I
• Keep a List of drug name and dosage in
L patient’s chart
Rational Prescribing: TIDE Approach
T Allow time to address medication issues

I Understand individual variation

D Avoid potential dangerous drug- drug interactions

E Educate patients regarding treatment

POLYPHARMACY
RECOMMENDATIONS
• Before adding a second medication:
• Ensure previous adequate monotherapy trials with adequate dose and duration;
• Ensure treatment compliance
• Know about potential drug interactions
• Set goals for treatment, and educate the patient about how long the medications will be
continued and what are the desired effects from the treatment?
• Seek alternative options; adequate emphasis on psychosocial interventions
• Address the total drug load and the cost of treatment
Tips for Rational Polypharmacy
• In general, same-class polypharmacy should be avoided.
• · More than one medication from any of the following medication classes should not be
used in a single patient:

• Typical antipsychotics (haloperidol, fluphenazine, etc.),

• Selective serotonin reuptake inhibitors (paroxetine, fluoxetine, etc.),
• Tricyclic antidepressants (amitryptiline, imipramine, etc.),
• Monoamine oxidase inhibitors (phenelzine, tranylcypromine),
• Stimulants (methylphenidate, amphetamine), or
• Benzodiazepines (diazepam, alprazolam, etc.).
• · More than two antipsychotic medications, typical or atypical, should not be used
simultaneously.
 ICARUS
•
PSYCHOPHARMACOTHERAPY
ICARUS: Greek mythological figure whose
wings melted as he stubbornly flew too close
to the sun.
• Overzealously pursuing perfect treatment
outcomes through supratherapeutic dosing/
aggressive polypharmacy risk scorching the
patient
• Optimum pharmacotherapy with pre set
target should be goals of treatment!
CONCLUSION
THANK YOU!