12 Define the term polypharmacy. Dangerous load: polypharmacy. Reasons for the ineffectiveness of pharmacotherapy

11/03/2014

Today, almost 90% of patients receive five or more drugs at the same time. At the same time, the appointment of two dosage forms increases the risk of side effects by 3-5%, and five - by 20%.

Aspects of the problem of polypharmacy

The most rational approach to the treatment of any disease is etiological or pathogenetic therapy - the impact on the very cause of the disease or on the pathophysiological mechanisms underlying its development. With this approach, the appointment of only one etiologically or pathogenetically justified drug can save the patient from many manifestations of the disease and thus eliminate the need to prescribe a large number of drugs.

In turn, the simultaneous prescription of a large number of drugs or medical procedures to a patient, often unjustified and irrational, was called "polypharmacy". In a number of situations, polypharmacy is due to the desire of the doctor to please the patient (“bad doctor, because he prescribed little”), as well as the self-prescribing of a large number of drugs - often the “victims of advertising” prescribe the treatment themselves.

"Every medicine not indicated is contraindicated"

EAT. Tareev

From the point of view of common sense, polypharmacy is a negative phenomenon, as it leads to the unjustified introduction of foreign substances into the body and causes an increase in the cost of treatment.

Polypharmacy is closely related to the problem of drug interactions, which often cause the development of side effects. However, in some situations drug interactions may be clinically beneficial. Prescribing two drugs causes interactions in 6% of patients, the use of five drugs increases their frequency by up to 50%, while when using 10 drugs, the risk of drug interactions reaches almost 100%.

Polypharmacy makes it impossible to control the effectiveness of therapy, increases material costs, reducing compliance (adherence to treatment).

The economic aspect of the problem lies in the fact that the spread of polypharmacy exhausts the already small resources of domestic healthcare and increases the financial burden of patients.

It is possible to limit the unreasonable use of a large number of drugs if the doctor uses in his practice a limited range of effective drugs, knowing about the features of their pharmacokinetics and pharmacodynamics, drug interactions, nuances of use, tolerability, etc.

in obstetrics and pediatrics

According to the results of the largest international study conducted by WHO, involving 14,778 pregnant women from 22 countries, it was found that 86% of women were taking at least one drug. The average number of drugs used was 2.9 (from 1 to 15).

More alarming data were obtained in a Russian study - 100% (543) of pregnant women received drug therapy, and only 1.5% of them took vitamins and microelements. At the same time, 62% of pregnant women were prescribed 6-15 drugs, 15% - 16-20 and 5% - 21-26.

The main complications of pharmacotherapy in pregnant women are termination of pregnancy, prematurity, overmaturity, death of the fetus or newborn, intrauterine malnutrition. As a result of the occurrence of side effects of drugs prescribed to pregnant women, the risk of teratogenic, embryotoxic and fetotoxic effects on the fetus increases, which manifest themselves, respectively, before the 3–5th week of pregnancy, 3–8th week or later. Embryotoxic effects damage the zygote and blastocyst, resulting in the death of the embryo. Teratogenic exposure disrupts the maturation of the embryo, leads to the death of the fetus or the occurrence of multiple malformations. Fetotoxic effect causes a violation of the development of the fetus in late pregnancy, causing multiple lesions of its organs.

In addition, polypharmacy can provoke dysfunctions of the cardiovascular and respiratory systems, as well as the development of acute renal failure in pregnant women.

Increasingly, pediatricians are also sounding the alarm, since the drug load that children receive is often excessive and unreasonable. A typical example is the appointment of an antibacterial drug and several immunomodulators for acute respiratory infections. As you know, antibiotics are by no means safe, especially in young children, and the effect of immunomodulators on the immune status of a child is often unknown and unpredictable. Given this, any medical appointment must be carefully weighed and justified.

The vicious circle of polymorbidity

As a rule, the doctor's desire to prescribe several drugs to the patient at once is due to the patient's simultaneous signs of damage to various organs and systems (cardiovascular, digestive, nervous, etc.). Therefore, it is obvious that polypharmacy is directly related to polymorbidity (the presence of several diseases in one person) and is one of the urgent problems of modern medicine, primarily gerontology and geriatrics. The fact is that, due to the age-related characteristics of pharmacokinetics, the risk of developing adverse reactions in elderly patients is 5–7 times higher than in young patients, and when using three or more drugs, it is 10 times higher. Doctors do not always take these side effects into account, because they regard them as a manifestation of polymorbidity, which entails the appointment of even more drugs, closing the "vicious circle". It should be noted that drug interactions arising in such a situation lead to a decrease in the effectiveness of pharmacotherapy.

In turn, according to experts, the simultaneous treatment of several diseases requires a detailed analysis of the compatibility of drugs and careful adherence to the rules of rational pharmacotherapy based on the postulate of the outstanding clinical pharmacologist B.E. Votchala: "If a drug is devoid of side effects, one should consider whether it has any effects at all."

Prepared by Alexandra Demetskaya,
cand. biol. Sciences

Literature

1. All-Russian Internet Congress of Internal Medicine Specialists, February 14-15, 2012 http://med-info.ru/content/view/794, http://internist.ru/sessions/events/events_227.html

2. Interaction of drugs and the effectiveness of pharmacotherapy / L.V. Derimedved, I.M. Pertsev, E.V. Shuvanova and others - Kh., 2002; Drug safety. Guidelines for pharmacovigilance / Ed. A.P. Viktorova, V.I. Maltseva, Yu.B. Belousov. - K., 2000.

3. Polypharmacy in obstetrics, perinatology and pediatrics // Medical Bulletin. - 2011; Issue. No. 557.

4. Strizhenok E.A. The use of drugs during pregnancy: the results of a multicenter pharmacoepidemiological study / E.A. Strizhenok, I.V. Gudkov, L.S. Strachunsky // Clinical microbiology and antimicrobial chemotherapy. - 2007; No. 2: 162–175.

Expert opinion:

Inna Lubyanova, Ph.D. honey. Sci., Leading Researcher at the Clinic of Occupational Diseases of the State Institution "Institute of Occupational Medicine of the National Academy of Medical Sciences of Ukraine":

The desire to improve the quality of prescribed drugs often leads to the opposite result. Therefore, I am categorically against polypharmacy, since the simultaneous use of more than six drugs (even different therapeutic groups) can be harmful to health. This is due to the fact that drugs can either neutralize the effect of each other or one of the active substances, or enhance the therapeutic effect, or cause the development of side effects.

I would like to advise pharmacists who are approached with a request to dispense more than five drugs, first of all, ask the visitor who exactly they are intended for. If this appointment is made to one person, the pharmacist must tell not only how to take this or that drug, but also warn about possible side effects. It is necessary to remember about the compatibility of drugs. If a visitor asks for drugs of one group, the pharmacist should advise him to check with the doctor in what order the prescribed drugs should be taken. And, of course, the pharmacist himself should not offer the visitor medicines of unidirectional action.

I would like to note that recently the number of combination drugs, the so-called "2 in 1" or even "3 in 1" for the treatment of certain diseases, in particular, arterial hypertension, respiratory infections, etc., has increased. Such combinations increase compliance, contribute to achieving better therapeutic effect and reduce the drug load on the body.

As for general practice, the number of drugs taken by our compatriots can often replace breakfast, lunch and dinner. At the same time, a person, as a rule, does not have time to modify his lifestyle and, accordingly, to improve its quality. But often the right lifestyle allows you to get rid of taking "extra" drugs and protect yourself from possible side effects. In addition, one should not forget about physiotherapeutic methods of treatment, which can replace a number of drugs.

Thus, it is necessary to strive for a minimum intake of drugs and, if possible, use non-drug methods of treatment as much as possible. Therefore, I always advocate a healthy lifestyle and the rejection of bad habits, advising my patients to spend more time in the fresh air and get positive emotions.

“Pharmacist Practitioner” №2′ 2014

L.B. Lazebnik, Yu.V. Konev, V.N. Drozdov, L.I. Efremov
Department of Gerontology and Geriatrics, Moscow State University of Medicine and Dentistry; Organizational and methodological department for therapy of the Moscow Department of Health; Central Research Institute of Gastroenterology

Polypharmacy [from "poly" - a lot and "pragma" - an object, a thing; synonym - polytherapy, excessive treatment, polypharmacy, "polypharmacy" (English)] - the redundancy of medical prescriptions has been and remains a very widespread and little-studied problem in modern clinical medicine.

The most well-known drug or drug polypharmacy (polypharmacy, polypharmacotherapy) is the simultaneous administration of several drugs in elderly patients. "Massive drug strike" (the author's term), as a rule, receives the most vulnerable contingent of patients, i.e. people suffering from polymorbidity - simultaneously occurring several diseases in various phases and stages. Most often these are elderly patients.

The number of diseases per patient in a geriatric hospital is shown in Fig. 1.

It is noteworthy that with increasing age, the index "number of diseases/one patient" decreases. This happens for several reasons. Firstly, people who suffer from fewer chronic diseases live to advanced years. Secondly, some chronic diseases are known to involute or disappear with age (for example, duodenal ulcer). Thirdly, under the influence of treatment, many diseases acquire a different clinical form ("drug" or "iatrogenic polymorphosis"). Examples are the transformation of a painful form of coronary heart disease into a painless form during long-term treatment with antianginal drugs or the disappearance of angina attacks and the normalization of blood pressure after implantation of a pacemaker.

It is polymorbidity, which forces the patient to be observed simultaneously by doctors of several specialties, is the reason for drug polypharmacotherapy as an established practice, since each of the specialists observing the patient, according to standards or established practice, is obliged to carry out targeted appointments.

On fig. 2 shows the profiles of doctors who simultaneously observe an elderly outpatient in one of the Moscow polyclinics.

Our many years of experience in clinical and expert evaluation of the quality of medical and diagnostic care shows that in most cases the principle that the attending physician follows when prescribing several drugs to the patient at the same time reflects his desire to cure all the diseases that the patient has at once (preferably, quickly), and at the same time prevent all possible complications (preferably more reliable).

Guided by these good intentions, the doctor prescribes drugs known to him according to the usual schemes (sometimes "for pressure", "for constipation", "for weakness", etc.), at the same time thoughtlessly combining the generally correct recommendations of numerous consultants who consider how It has already been mentioned above that it is mandatory to introduce additional treatment according to your profile.

As an example, we cite the simultaneous prescription of 27 different drugs in the amount of more than 50 tablets per day to a disabled veteran of the Great Patriotic War (we are talking about drug provision under the DLO system), and the patient not only insisted on receiving them, but also took everything! The patient suffered from twelve diseases and was seen by eight specialists (therapist, cardiologist, gastroenterologist, neurologist, endocrinologist, urologist, ophthalmologist and otorhinolaryngologist), each of whom prescribed "his" treatment, without even trying to somehow correlate it with the recommendations of other specialists. Naturally, the therapist raised the alarm. Believe me, it cost a lot of work to convince the patient to stop taking a huge amount of drugs. The main argument for him was the need to "pity the liver."

The problem of polypharmacotherapy has been around for a long time.

Being the head of the Department of Pharmacology of the Military Medical Academy in 1890-1896, I.P. Pavlov once wrote: "... When I see a prescription containing a prescription for three or more drugs, I think: what a dark power lies in it!" It is noteworthy that the mixture proposed by I.P. Pavlov in the same period, named after him, contained only two drugs (sodium bromide and caffeine), acting in different directions on the functional state of the central nervous system.

Another Nobel laureate, a German doctor, bacteriologist and biochemist Paul Ehrlich, dreamed of creating a medicine that alone, like a "magic bullet", would kill all diseases in the body without causing him the slightest harm.

According to I.P. Pavlov, polypharmacy should be considered the simultaneous appointment of three or more drugs to the patient, and according to P. Erlich, more than one.

There are several reasons for drug polypharmacotherapy, both objective and subjective.

The first objective reason is, as we have already pointed out, senile polymorbidity ("redundancy of pathology"). The second objective reason in geriatrics is the absence, weakening or inversion of the expected final effect of the drug due to a change in drug metabolism in a fading organism with naturally developing changes - a weakening of metabolic processes in the liver and tissues (including the activity of cytochrome P450), a decrease in the volume of circulating blood, decreased renal clearance, etc.

Getting an insufficient or perverted effect from the prescribed drugs, the doctor changes the treatment most often in the direction of increasing the number of pills or replacing the drug with a "stronger" one. As a result, iatrogenic pathology develops, which was previously called "drug disease". Now such a term does not exist: they talk about "undesirable" or "side" effects of drugs, hiding behind the terms the inability or unwillingness to see the systemic effect of the active substance on the human body as a whole.

A careful analysis of the gradual development of numerous diseases in the elderly makes it possible to identify syndromes that characterize the systemic effects of drugs in the body of an old person - psychogenic, cardiogenic, pulmogenic, digestive, enterogenic, hepatogenic, otogenic, etc.

These syndromes, caused by prolonged exposure to drugs on the body, clinically look and are regarded by the doctor as a disease per se or as a manifestation of natural aging. We believe that a doctor reflecting on the essence of things should pay attention to the accelerated pace of development of the newly recorded syndrome and try to at least chronologically connect it with the time the drug was started. It is the rate of development of the "disease" and this connection that can tell the doctor the true genesis of the syndrome, although the task is not easy.

These final systemic effects that develop with long-term, often long-term use of drugs by elderly people are almost always perceived by the doctor as a manifestation of aging of the body or the addition of a new disease and always entail additional prescription of drugs aimed at curing the "newly discovered disease".

So, long-term use of antispasmodics or some antihypertensive drugs can lead to atonic constipation, followed by prolonged and most often unsuccessful self-medication with laxatives, then to intestinal diverticulosis, diverticulitis, etc. At the same time, the doctor does not suggest that constipation has changed the intestinal flora, the degree of hyperendotoxinemia has increased, exacerbating heart failure. The doctor's tactic is to intensify the treatment of heart failure. The prognosis is clear. Dozens of such examples could be cited.

Simultaneous administration of drugs leads to drug interactions in 6% of patients, 5 increases their frequency to 50%, when taking 10 drugs, the risk of drug interactions reaches 100%.

In the United States, up to 8.8 million patients are hospitalized annually, of which 100-200 thousand die due to the development of adverse drug-related adverse reactions.

The average number of drugs taken by older patients (both prescribed by doctors and self-administered) was 10.5, while in 96% of cases, doctors did not know exactly what their patients were taking.

On fig. 3 shows the average daily number of drugs taken by patients in a geriatric hospital (according to our employee O.M. Mikheev).

Physically more active people took fewer drugs, and with increasing age, the amount of drugs consumed decreased, which confirms the well-known truth: less sick people live longer.

From the objective causes of drug polypharmacotherapy, subjective ones follow - iatrogenic, caused by the appointments of a medical worker, and discompliant, due to the actions of the patient receiving treatment.

The basis of iatrogenic causes is primarily a model of diagnostic and treatment tactics - treatment should be complex, pathogenetic (with an impact on the main links of pathogenesis), and the examination should be as complete as possible. These, in principle, absolutely correct foundations are laid down in the undergraduate doctor's training programs, programs and postgraduate education.

Education on the interaction of drugs cannot be considered sufficient; doctors have very little knowledge of the relationship between drugs, nutritional supplements and meal times. It is not uncommon for a doctor to make a decision to prescribe a drug, being under the suggestive influence of recently received information about the miraculous properties of the next pharmaceutical novelty, confirmed by the "unique" results of the next multicenter study. However, for advertising purposes, it is silent that patients were included in such a study according to strict criteria, excluding, as a rule, a complicated course of the underlying disease or the presence of other "comorbid" diseases.

Unfortunately, we have to state that in undergraduate and postgraduate education programs very little attention is paid to the problem of in vivo compatibility of drugs, and the issues of long-term use of this drug or drugs of this pharmacological group are not touched upon at all. Opportunities for self-education of a doctor in this area are limited. Not everyone has access to compatibility tables for two drugs, and as for three or more, it seems that modern clinical pharmacology has not yet begun to search for an answer to this vital question.

At the same time, it should be noted that we ourselves can form an idea of this only on the basis of long experience. Reasonable arguments, based on many years of observation, made it possible to abandon the recommendations for lifelong use of estrogen replacement therapy; be wary of recommendations for lifelong use of proton pump inhibitors, etc.

Volens nolens, even a highly educated thinking doctor who starts treating a patient with polymorbidity, every time he has to work in a cybernetic "black box" system, i.e. situations where the decision maker knows what he inputs into the system and what he should get as output, but has no idea about the internal processes.

The main reason for polypharmacotherapy on the part of the patient is discompliance with medical prescriptions.

According to our research, up to 30% of patients did not understand the doctor's explanations regarding the names, the regimen of taking drugs and the goals of treatment, and therefore took up self-medication. About 30%, after listening to the doctor and agreeing with him, independently refuse the prescribed treatment for financial or other reasons and change it, preferring to supplement the recommended treatment or the usual (essentially ineffective) medicines or remedies that they were advised to use by friends, neighbors, relatives or other medical (including ambulance) workers.

A significant role in perverting the treatment is also played by aggressive advertising of nutritional supplements, which are presented by the media as a "unique remedy ..." ("order urgently, stock is limited ..."). The effect of uniqueness is enhanced by the reference to the mysterious ancient Eastern, African or "Kremlin" origin. The "guarantee" of the effect is sometimes laid down in the name of the product or the hypocritical recommendation to consult a doctor, who, even with a great desire, will not find any objective information about this miracle remedy. References to the popularity of the "ancient remedy" in the claimed country of origin are untenable: questions asked in this country about this "remedy" cause bewilderment among the local population.

In our practice, we appeal to common sense: we advise our patients not to believe the advertising coming from the media about these miracle drugs, we convince them that the manufacturer would first of all inform the professional community about the real effectiveness of the drug, and not on radio or television.

Given all of the above, one cannot help but welcome the creation of a Corresponding Member headed by. RAMS prof. V.K. Lepakhin of the Federal Center for Monitoring the Safety of Medicines of Roszdravnadzor.

Our many years of experience allows us to present our vision of pharmacotherapy options for polymorbidity (Fig. 4).

We single out rational and irrational variants of pharmacotherapy for polymorbidity. The condition for successful application and achievement of the goal with a rational option is the competence of the doctor and the patient. In this case, the effect is achievable using a reasonable technology, when, due to clinical necessity and pharmacological safety, the patient is prescribed several drugs or forms at the same time.

In the presence of several diseases, it is necessary to prescribe drugs with a proven absence of interaction. To achieve a greater effect in the treatment of one disease in order to potentiate one effect, single-acting drugs are prescribed in the form of several dosage forms of different names or in the form of ready-made dosage forms of factory production (for example, an angiotensin-converting enzyme inhibitor and a diuretic in one tablet - "polypills", in the form tablets of several drugs differing in chemical composition, but sealed in one blister, and even with an indication of the time of administration, etc.).

Another option for rational pharmacotherapy for polymorbidity is the principle of multipurpose monotherapy that we are developing, i.e. simultaneous achievement of a therapeutic goal in the presence of a systemic effect of this drug.

Thus, the indications for prescribing the α-blocker doxazosin for men suffering from arterial hypertension and prostatic hyperplasia, included in the European and national recommendations, were developed in detail by our employee E.A. Klimanova, who also showed that when prescribing this drug, correction of mild forms of insulin resistance is possible. and hyperglycemia. Another of our collaborators, M.I.Kadiskaya, for the first time showed the systemic non-antilipidemic effects of statins, later called pleiotropic.

We believe that it is multitarget monopharmacotherapy that will largely allow avoiding those irrational options for pharmacotherapy in polymorbidity, which are presented in the right columns of the scheme and which were mentioned above.

Thus, we believe that polypharmacy should be considered the appointment of more than two drugs of different chemical composition at one time or within 1 day.

Reasonable drug polypharmacotherapy in modern clinical practice, subject to its safety and expediency, is not only possible and acceptable, but necessary in difficult and difficult situations.

Unreasonable, incompatible, simultaneous or within 1 day prescribed a large number of drugs to one patient should be considered irrational polypharmacy or "drug polypharmacy".

It is appropriate to recall the opinion of the famous therapist I.Magyar (1987), who, based on the principle of the unity of the treatment and diagnostic process, proposed a broader interpretation of the concept of "polypharmacy". He believes that therapeutic polypharmacy is often preceded by diagnostic polypharmacy (excessive actions of a doctor aimed at diagnosing diseases, including using ultra-modern, as a rule, expensive research methods), and diagnostic and therapeutic polypharmacy, closely intertwined and provoking each other, give rise to countless iatrogenic. Both types of polypharmacy are generated, as a rule, by "undisciplined medical thinking".

It seems to us that this very complex issue requires special study and discussion.

On the one hand, it is impossible not to admit that many doctors, especially young ones, who have little knowledge of clinical diagnostics, of the non-interchangeability and complementarity of different diagnostic methods, prefer to prescribe "additional" examinations ("instrumentalism" from ignorance!), Having received a conclusion, they often do not even bother getting to know him. In addition, a rare doctor in modern practice accompanies the patient during diagnostic manipulations, is limited to a ready-made conclusion and does not delve into the structure of the original indicators.

The huge workload of laboratories and technical diagnostic services is due to approved standards and diagnostic schemes, which do not always take into account the material, technical and economic capabilities of a given medical facility.

The diagnostic component of the cost of the treatment and diagnostic process is steadily increasing, the financial needs of modern health care cannot be sustained by the economy of even highly developed countries.

On the other hand, any doctor can easily prove that the "additional" diagnostic examination prescribed by him was extremely necessary as having a targeted purpose and, in principle, will be right.

Each doctor can give more than one example when a severe or prognostically unfavorable disease was detected during an accidental ("just in case"!) Diagnostic manipulation. Each of us is a supporter of an early and ongoing cancer search.

Modern diagnostic systems are practically safe for health, the manipulations used in their implementation are easily tolerated, so the concept of "benefit-harm" becomes conditional.

Apparently, speaking about the modern aspects of "diagnostic polypharmacy", one should keep in mind the "goal-cost" rationale.

We deliberately use the concept of "goal", which is replaced by the term "expediency" in some guidelines on pharmacoeconomics. Some politicians-economists who are not ready for key roles easily substitute economic "expediency" for the ethical concept of "goal". So, according to the opinion of some of them, the state provision of the medical and diagnostic process is inappropriate, etc.

The aim is to detect a chronic disease as early as possible. Thus, the conclusion suggests itself that it is necessary to conduct a detailed medical examination multiple times throughout a person’s life, i.e. medical examination, which implies the obligatory obtaining of results using laboratory, endoscopic and radiation technologies.

Based on the Moscow experience, we believe that such an option for the development of healthcare is possible.

We offer our rubricification of different variants of polypharmacy (Fig. 5).

We believe that in order to prevent unreasonable diagnostic and therapeutic polypharmacy in people of older age groups, the attending physician must adhere to the following fundamental provisions.

The risk of examination should be less than the risk of an unidentified disease.
An additional examination must be prescribed primarily to confirm, but not to reject a preliminary diagnosis, which must be substantiated.
Follow the rule formulated by the famous therapist and clinical pharmacologist B.E. Votchal: "Less drugs: only what is absolutely necessary" . The absence of direct indications for prescribing the drug is a contraindication.
Adhere to a "low dose regimen" for almost all drugs, except for antibacterials ("only the dose makes the medicine poison"; however, the opposite is also true: "only the dose makes the poison medicine").
Correctly choose the ways of removing drugs from the body of an elderly person, giving preference to drugs with two or more ways of excretion.
Each appointment of a new drug must be carefully weighed, taking into account the peculiarities of the drug's action (pharmacokinetics and pharmacodynamics) and the so-called side effects. Note that the patient himself should be familiarized with them. Prescribing a new medicine, you need to think about whether it is worth canceling some "old" one.

The presence in an elderly patient of multiple pathologies, mosaic and blurring of clinical manifestations, a complex and bizarre plexus of complaints, symptoms and syndromes caused by clinical manifestations of aging processes, chronic diseases and medicinal effects (Fig. 6), make treatment a creative process, in which the best solution is possible only thanks to the mind of the doctor.

Unfortunately, modern specialists, especially narrow ones, have begun to forget a long-established simple rule that allows avoiding drug polypharmacy: the patient (of course, except for urgent situations) should not receive more than 4 drugs at the same time, and issues of increasing the volume of treatment should be decided jointly by several specialists (concilium) . With a joint discussion, it is easier to predict a possible drug interaction, the reaction of the whole organism.

When treating each specific patient, one should act according to the old commandments: "est modus in rebus" (observe the measure) and "non nocere" (do no harm).

Literature

Encyclopedic dictionary of medical terms. MEDpress, 1989.
Lazebnik L.B. Practical geriatrics. M., 2002.
Lazebnik L.B., Konev Yu.V., Mikheeva O.M. Multipurpose monotherapy with α-blockers in geriatric practice. M., 2006.
Lee E.D. Diagnosis and treatment of painless myocardial ischemia. Dis. ... Dr. med. Sciences, 2005.
Tokmachev Yu.K., Lazebnik L.B., Tereshchenko S.N. Changes in the functional state of the body in patients with coronary heart disease after implantation of various types of pacemakers. Circulation. 1989; 1:57-9.
Bashkaeva M.Sh., Milyukova O.M., Lazebnik L.B. The dependence of the number of daily drugs taken on the functional activity of the elderly. Clinical gerontol. 1998; 4:38-42.
Mokhov A.A. Problems of litigation of cases on compensation for harm caused to the health or life of a citizen in the provision of medical care. Honey. right. 2005; 4.
Ostroumova O.D. Features of the treatment of cardiovascular diseases in the elderly. Cardiac insufficient 2004; 2:98-9.
Klimanova E. A. Monotherapy with alpha-blocker doxazosin for arterial hypertension and benign prostatic hyperplasia in men of older age groups. Dis. ... cand. honey. Sciences. 2003.
Kadiska M.I. Non-lipid effects of statins and fibrates in the secondary prevention of coronary heart disease in women. Dis. ... cand. honey. Sciences. 1999.
Bleuler 1922 (quoted by: Elshtein N.V. Mistakes in gastroenterology. Tallinn, 1991; 189-90).
Magyar I. Differential diagnosis of diseases of internal organs. Ed. Hungarian Academy of Sciences, 1987; I-II: 1155.
Lazebnik L.B., Gainulin Sh.M., Nazarenko I.V. and other Organizational measures to combat arterial hypertension. Ros. cardiological magazine 2005; 5:5-11.
Votchal B.E. Problems and methods of modern therapy. Proceedings of the 16th All-Union Congress of Therapists. M.: Medicine, 1972; 215-9.

5 , Razuvanova E.M. 5 , Makeev D.G. 5 , Askerova A.A. 5
1 FGBOU VO RNIMU them. N.I. Pirogov of the Ministry of Health of Russia, Moscow
2 OSB FGBOU VO "RNIMU them. N.I. Pirogov" of the Ministry of Health of Russia "RGNCC", Moscow; Federal State Autonomous Educational Institution of Higher Education "Peoples' Friendship University of Russia", Moscow
3 OSB FGBOU VO "RNIMU im. N.I. Pirogov" of the Ministry of Health of Russia "RGNCC", Moscow; FGBOU VO "RNIMU them. N.I. Pirogov" of the Ministry of Health of Russia, Moscow
4 OSB Russian Gerontological Research and Clinical Center - FGBOU VO RNIMU named after N.I. Pirogov of the Ministry of Health of Russia, Moscow, Russia
5 Federal State Autonomous Educational Institution of Higher Education "Peoples' Friendship University of Russia", Moscow

The population of the Earth is aging, and this process is largely due to advances in pharmacology. The appointment of modern drugs (MP) to the elderly helps prolong their lives, prevents the development of certain diseases and complications, but the use of an excess amount of drugs by the elderly can cause adverse reactions, including serious and fatal. However, as patients age and become frail, the focus of pharmacotherapy is shifting towards controlling disease symptoms, improving quality of life, and minimizing the use of potentially harmful prophylactic drugs that will provide little benefit over a relatively short life expectancy.
To reduce the risk of negative consequences of polypharmacy in elderly patients, a number of approaches can be recommended, including educational activities, auxiliary computer systems, as well as modern methods presented by the authors in this article: anticholinergic load calculation scales, STOPP / START criteria, Beers criteria, Rationality Index drugs, comorbidity indices. The use of these tools during a drug audit can reduce the drug load and improve the safety of pharmacotherapy.

Keywords: elderly, safety, polypharmacy.

For citation: Tkacheva O.N., Pereverzev A.P., Tkacheva, Kotovskaya Yu.V., Shevchenko D.A., Apresyan V.S., Filippova A.V., Danilova M.G., Razuvanova E.M., Makeev D.G., Askerova A.A. Optimization of drug prescriptions in elderly and senile patients: is it possible to defeat polypharmacy? // RMJ. 2017. No. 25. S. 1826-1828

Optimization of medicinal prescriptions in patients of elderly and senile age: is it possible to defeat polypharmacy?
Tkacheva O.N. 1, Pereverzev A.P. 1,2 , Runikhina N.K. 1 , Kotovskaya Yu.V. 1,2 Shevchenko D.A. 2, Apresyan V.S. 2, Filippova A.V. 2, Danilova M.G. 2,
Razuvanova E.M. 2, Makeev D.G. 2 , Askerova A.A. 2

1 Russian gerontological scientific and clinical center, Moscow
2 Peoples" Friendship University of Russia, Moscow

The population of the Earth is aging, and this process is largely due to advances in pharmacology. The appointment of modern medicines to elderly people contributes to the prolongation of their life, prevents the development of certain diseases and complications, but the use of excessive amounts of drugs by elderly people can lead to adverse drug events, including serious and fatal ones. At the same time, as the patients become older and frailer, the emphasis of pharmacotherapy shifts towards controlling the symptoms of diseases, improving the quality of life and minimizing the use of potentially dangerous preventive drugs that will benefit little over a relatively short expected life expectancy . To reduce the risk of negative consequences of polypharmacy in elderly patients, a number of approaches can be recommended that include educational activities, ancillary computer systems, and modern methods presented by the authors in this article: anticholinergic load scales, STOPP / START criteria, Bierce criteria, index of rational drugs administration, comorbidity indices. The use of these tools during the drug audit can reduce the drug load and improve the safety of pharmacotherapy.

key words: elderly, safety, polypharmacy.
For quote: Tkacheva O.N., Pereverzev A.P., Runikhina N.K. et al. Optimization of medicinal prescriptions in patients of elderly and senile age: is it possible to defeat polypharmacy? // RMJ. 2017. No. 25. P. 1826–1828.

The article is devoted to the optimization of drug prescriptions in elderly and senile patients. To reduce the risk of negative consequences of polypharmacy in elderly patients, a number of approaches can be recommended, including educational activities, auxiliary computer systems, as well as other modern methods presented in the article.

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