£199.99 £139.99 for one year of Unlimited learning. Offer ends on 14 November 2022 at 23:59 (UTC). T&Cs apply

Find out more
Appropriate and problematic polypharmacy
Skip main navigation

Appropriate and problematic polypharmacy

When is polypharmacy a problem and when is it appropriate?
Pill dispenser
© University of York/HYMS

Patients might be prescribed a large number of medicines, but it doesn’t mean that those medications are inappropriate.

As a consequence, polypharmacy may be defined as appropriate or inappropriate1.

APPROPRIATE Polypharmacy:

  • Drugs prescribed for the purpose of achieving a specific therapeutic objective that has been agreed with the patient; where the medicines are prescribed according to best evidence and achieve the intended goals.

PROBLEMATIC Polypharmacy:

  • When multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realised.
  • Describes when the downsides of using particular medicines outweigh the (potential) benefits.

So what evidence is there of appropriate polypharmacy?

Well a common example you may encounter in practice is a patient discharged on multiple new medications after an acute admission with a myocardial infarction. The table below highlights research demonstrating a 75% cumulative relative-risk reduction from taking four drugs for secondary prevention in cardiovascular disease1, 2.

Reducing relative and absolute risk through polypharmacy

Figure 1: Reducing relative and absolute risk through polypharmacy. Table adapted from source2, where there are details of how cumulative risk reduction was calculated.

Polypharmacy has been strongly associated with unplanned hospitalisation, though this effect is actually reduced in people with multiple conditions, who are less likely to experience an unplanned admission3. Only the most extreme levels of polypharmacy in people with multiple health problems were found to be associated with increased hospital admissions. Therefore, it can be wrong to assume that polypharmacy is always hazardous or represents poor care.

Therefore, simply reducing the number of medicines isn’t the solution. A flexible approach accounting for the clinical context and patient preferences is key.

We’ve considered how appropriate polypharmacy can definitely be beneficial. However, Brian’s case may tell a different story of problematic polypharmacy.

Past Medical History

  • Hypertension
  • Type 2 diabetes
  • Osteoarthritis
  • Overactive bladder
  • Depression
  • Gout
  • Dry eye syndrome
  • Constipation


  • Ramipril
  • Indapamide
  • Metformin
  • Amitriptyline
  • Co-codamol 30/500
  • Oxybutynin
  • Allopurinol
  • Citalopram
  • Systane eye drops
  • Fybogel
  • Atorvastatin
Let’s consider Brian’s medications above. With all the interactions we identified earlier, he certainly has the potential for problematic polypharmacy. So if you encountered Brian in practice, where would you start?

You may have spotted that his gout could have been precipitated by his indapamide, so your priority may be to review this. However, Brian’s priority could be to reduce his constipation, which may have been triggered by his oxybutynin, amitriptyline or co-codamol. If we stopped these, it could negatively impact on his other conditions, including his osteoarthritis and overactive bladder. Where do we start?!

Ideally we want to tailor our de-prescribing, taking account of Brian’s priorities, whilst using our own wisdom to guide decision making. This is where understanding some of the potential barriers to tailored de-prescribing and having a structured approach could help!

We’ll consider this further in the coming steps…


  1. The King’s Fund. Polypharmacy and Medicines Optimisation: making it safe and sound. 2013. Available from: https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation [Accessed 17/02/2022]
  2. Yusuf S. ‘Commentary: Two decades of progress in preventing vascular disease’. The Lancet. 2002; 360:2-3.
  3. Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol. 2014 Jun; 77(6): 1073–1082. DOI: 10.1111/bcp.12292
© University of York/HYMS
This article is from the free online

WISDOM - Tomorrow’s Doctor, Today: Supporting Today’s Expert Generalist GP

Created by
FutureLearn - Learning For Life

Our purpose is to transform access to education.

We offer a diverse selection of courses from leading universities and cultural institutions from around the world. These are delivered one step at a time, and are accessible on mobile, tablet and desktop, so you can fit learning around your life.

We believe learning should be an enjoyable, social experience, so our courses offer the opportunity to discuss what you’re learning with others as you go, helping you make fresh discoveries and form new ideas.
You can unlock new opportunities with unlimited access to hundreds of online short courses for a year by subscribing to our Unlimited package. Build your knowledge with top universities and organisations.

Learn more about how FutureLearn is transforming access to education