Polypharmacy risk revealed for cirrhosis patients


By Geir O'Rourke

20 Nov 2023

Polypharmacy is common in Australian patients with cirrhosis, two thirds of whom are on at least five different prescribed medicines at any point in time, researchers have found.

Based on PBS data, the finding highlights the need for pharmacovigilance and targeted medication safety efforts in this population, particularly given most of their therapeutics are prescribed by community GPs, they say.

The retrospective cohort study included 522 adults (mean age 60 years, 70% male, 34% decompensated at recruitment) from the Brisbane region participating in the CirCare study, whose PBS records were analysed for all medicines dispensed between January 2016 and June 2020.

Together, they were dispensed a combined 89,615 prescriptions during the follow-up period, representing a median of 136 prescriptions and a median of 16 unique medicines per patient.

The most commonly used medicines were proton pump inhibitors (PPIs), which were dispensed at least once to 73% of patients, opioids (68%) and antibiotics (89%).

Concerningly, 54% of participants were on PPIs long-term, despite the fact this was discouraged due to an increased risk of serious infections and hepatic encephalopathy, the researchers noted in Drugs – Real World Outcomes (link here).

Beyond that, polypharmacy appeared to increase over the study period, with the median number of dispensed medicines per-patient rising from six in January-June 2016 to seven in January-June 2020.

There was as also a significant increase in the likelihood of opioid prescribing over time, as did prescribing of gabapentinoids, which were dispensed to almost a quarter of participants over the study period.

Interestingly, GPs prescribed 69% of all total dispensed medicines, 72% of those considered ‘unsafe’ and 73% of those of unknown safety, according to the researchers.

“Whilst medicines may have been initiated (e.g. drug and dose selection) by the prescriber, some GP prescriptions may have been repeated/written upon instruction from a specialist, and some specialist prescriptions may have been for a medication not specific to their specialty,” they added.

“Regardless of the initiating prescriber, regular medication review and monitoring are essential steps in the medication management cycle that should be undertaken with every prescription.”

“The large proportion of GP prescriptions in our study highlights the reliance on primary care to manage day-to-day pharmacotherapy, including of potentially ‘unsafe’ drugs, for people with cirrhosis.”

The authors concluded: “These observational data suggest that polypharmacy is common, and that PPIs, opioids and benzodiazepines may be overused in Australian patients with cirrhosis.”

“Further exploration of indication and potential alternative therapies is required.”

“Pharmacovigilance and future medication safety efforts should target high-risk prescribing practices, educating GPs and promote medication rationalisation in the community.”

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