Adding a Sixth Step: Emphasizing Pharmacists’ Roles in Managing Polypharmacy

We thank Drs Tarn and Schwartz for proposing a plan to reduce inappropriate prescribing patterns in their article “Polypharmacy: A Five-Step Call to Action for Family Physicians.”¹ More concerning than the drug-drug interactions pointed out by Tarn and colleagues, polypharmacy is associated with several negative health outcomes for older adults, including an increased risk of hospital admissions, adverse drug events, and mortality.² We applaud the authors’ thoughtful suggestions to address polypharmacy. However, we believe a vital sixth step should be highlighted for this call to action: involve pharmacists to reduce polypharmacy and proactively train physicians on ways to prevent medication overutilization.

Pharmacists obtain the doctor of pharmacy (PharmD) degree and may complete optional residency training that allows them to specialize across the patient care continuum and become experienced educators. Regardless of added training, pharmacists can take a larger role in patient care to identify and address all types of medication therapy problems (MTPs), including polypharmacy. It is important for physicians and health care systems to advocate for pharmacists to provide comprehensive medication management in primary care offices, hospital settings, and community pharmacies.

While Tarn and Schwartz discuss pharmacist consultation to address polypharmacy, the scope of pharmacists’ contribution is potentially understated. A 2018 Cochrane systematic review acknowledged the importance of pharmacists in reducing potentially inappropriate medications.² Pharmacists working within primary care significantly address polypharmacy, inappropriate medication use, and encourage safer prescribing practices.³ Studies have shown that pharmacists in family medicine practices help identify MTPs and yield a significant decrease in the number of inappropriate medications prescribed.^3,4 Pharmacists have also demonstrated their role in the reduction of polypharmacy outside of primary care. For example, hospital-based pharmacists have successfully reduced the number of patients with polypharmacy while identifying MTPs.⁵ Often not utilized, community pharmacists are also able to optimize medication management in older adults. Community pharmacist interventions have resulted in discontinuation of Beers Criteria and other inappropriately prescribed medications.^6,7

Another area Tarn and Schwartz briefly discuss is educating trainees. Integrating pharmacists throughout medical school and residency education would allow for improved prescribing training and act as a proactive method to prevent polypharmacy. The inclusion of pharmacists in medical education could increase prescriber confidence, reduce inappropriate prescribing, and ultimately reduce avoidable adverse reactions.⁸ Similarly, while it is exciting that over 50% of family medicine residency programs have clinical pharmacists as faculty, resident education would be enhanced with more universal adoption.⁹

While the steps presented by the authors include pharmacists as a member of the interprofessional team, the extent to which pharmacists are able to assist in optimizing medications is more integral than suggested. We urge family physicians to utilize pharmacists as medication experts to reduce polypharmacy and improve appropriate prescribing, both in direct patient care and teaching roles. Ideally, this would mean hiring pharmacists to primary care offices and family medicine residency programs. Physicians can contact STFM’s Pharmacist Faculty Collaborative—a working group of clinical pharmacists—as a first step when seeking to add or enhance pharmacist involvement.