Polypharmacy Management Emerges as Critical Public Health Challenge Across Healthcare Settings

Care of adults with multiple medical conditions is often overly complex and rarely person-centered, leading to poor health outcomes, unsustainable levels of expenditure and avoidable environmental damage, all of which disproportionately affects the most vulnerable in society. Medication is the single most common healthcare intervention and generates the third highest cost of health expenditure.

Polypharmacy, commonly defined as the use of 5 or more medications, is increasingly prevalent, particularly among older adults and patients living with multiple chronic conditions. The vast majority of medical research, guidelines and contractual agreements have focussed on single targets for single disease states, whereas in reality most people have multimorbidities, requiring multiple treatments. Multimorbidity does not just affect the older adult. For example, 29% of people with multimorbidity are under the age of 65 years, and disproportionally come from the most deprived communities.

The resulting polypharmacy can be appropriate or inappropriate. Polypharmacy becomes inappropriate when the medication risks begin to outweigh the benefits for an individual, and this is the important area to consider rather than the number of medicines an individual is taking alone. Although pharmacotherapy is essential for disease management and improved quality of life, complex medication regimens are associated with an increased risk of adverse drug events, clinically significant drug-drug interactions, medication nonadherence, and hospitalizations.

Polypharmacy has been associated with negative clinical outcomes, including falls, cognitive impairment, frailty, and increased emergency department visits, particularly in older adults. Complex dosing schedules, look-alike or soundalike drug names, and frequent changes to therapy increase the risk of missed doses, therapeutic duplication, and inappropriate medication use.

Infectious Disease Care Challenges

Polypharmacy became one of the most important challenges in modern medicine, and it may be especially critical in infectious disease care. Aging, multimorbidity, and increasingly complex anti-infective regimens may converge in the same person, creating dense pharmacotherapeutic environments in which drug–drug interactions, adverse drug reactions, and adherence problems are common.

Polypharmacy is a complex interaction between long-term treatments for chronic conditions, prophylactic regimens, and time-limited antimicrobial courses, often layered on top of antiretrovirals, immunosuppressants, or oncological agents. During acute illnesses and transitions of care, medications are frequently started, stopped, and dose-adjusted while renal and hepatic function may fluctuate. If unmanaged, the polypharmacy and its dynamic may amplify the risk of toxicity, treatment failure, and antimicrobial resistance.

Geriatric literature has long shown that polypharmacy and drug-drug interactions complicate antimicrobial therapy in older adults, who are vulnerable to atypical presentations, organ dysfunction, and cumulative toxicity, due to age-related changes in body composition, hepatic blood flow, and renal clearance.

Beyond chronological age, frailty captures a multidimensional reduction in physiological reserve that increases susceptibility to medication-related harm during acute illness and therapeutic escalation. In emergency and critical care settings, frailty frequently coexists with polypharmacy and is associated with higher complexity of clinical decision-making and increased vulnerability to adverse drug events.

HIV and Tuberculosis Care

HIV care offers a paradigmatic example. Polypharmacy definition in people with HIV are heterogeneous but are consistently associated with advanced age and multimorbidity, as well as with potential drug-drug interactions, and increased anticholinergic risk with include an increased risk of falls and hospitalization. Polypharmacy in the context of HIV and ageing is not only a matter of toxicity, due to drug-drug interactions, but it may have an impact on the effectiveness of antiretroviral therapy through many other person-, treatment-, condition-, provider- and system-related factors that influence adherence.

Advances in infectious disease therapy have partially mitigated some sources of complexity, by simplifying antiretroviral therapy to once-daily tablet regimens, with improved safety and interaction profiles. By contrast, the net effect on total medication burden of antiretroviral therapy regimen simplification may appear neutral due to the increase of medication burden for non-HIV conditions.

Tuberculosis care epitomizes the potential issues between necessary multidrug therapy and the risks of polypharmacy. Standard and drug-resistant tuberculosis regimens are inherently complex and prolonged, and are frequently layered onto treatments for HIV, diabetes, cardiovascular disease, mental health disorders and other comorbidities. In a multidisciplinary tuberculosis clinic, patients with mycobacterial infections took on average 10 drugs.

Patient Education and Medication Reviews

Patient education is a fundamental component of effective polypharmacy management. Patients should be encouraged to understand the name, purpose, dosage, and timing of each medication they use, including OTC products and dietary supplements. In addition, herbal products, vitamins, and as-needed medications are frequently overlooked yet may contribute to clinically significant drug interactions.

Pharmacists can enhance patient understanding by using clear, nontechnical language and verifying comprehension through teach-back techniques. Additional interventions such as providing written medication lists, recommending pill organizers, and suggesting mobile reminder tools can further improve adherence and strengthen patient confidence.

Routine medication reviews, including comprehensive medication management and medication therapy management, are essential for identifying potentially inappropriate medications and aligning medication regimens with patient-specific goals. During these reviews, pharmacists evaluate each medication for appropriate indication, effectiveness, safety, and adherence. Encouraging patients to bring all prescription medications, OTC products, and dietary supplements to appointments (a practice commonly referred to as a brown bag medication review) helps ensure an accurate and complete medication profile.

Deprescribing and System Improvements

Deprescribing is a structured, clinician-guided process of tapering or discontinuing medications that no longer provide clinical benefit or pose potential harm. When approached collaboratively, deprescribing can improve clinical outcomes and quality of life without compromising disease control. Shared decision-making, clear communication, and close follow-up are essential to the success of deprescribing interventions.

Fragmented care is a key contributor to inappropriate polypharmacy, as patients often receive prescriptions from multiple prescribers, increasing the risk of therapeutic duplication and clinically significant drug-drug interactions. An important principle in improving the care of those with multimorbidity is to ensure an integrated care approach to health and social care services. This can help address medication systems, processes and procedures that support improved outcomes for people by helping reduce errors that result from disjointed ways of working.

Addressing inappropriate polypharmacy contributes to addressing the climate and sustainability strategy by both reducing the waste from the number of medicines unnecessarily prescribed and the reduction in carbon footprint from hospital admissions or primary care contacts due to medication-related harm.