Polypharmacy in IBD interferes with treatment adherence, therapeutic success

Polypharmacy (PP) arises in nearly one in five patients with inflammatory bowel disease (IBD), particularly in older adults and those with comorbidity, according to a study, adding that PP can complicate adherence to treatment and therapeutic success.

“Consequently, efforts should be made to include these variables in IBD studies, and to take them into consideration for the management of IBD patients in clinical practice,” the researchers said.

This retrospective study of a single-centre series sought to determine the prevalence of PP in a series of IBD patients by characterizing related factors and its association with poor disease outcomes. PP was defined as the simultaneous use of five or more drugs. The researchers evaluated disease outcomes, IBD treatment nonadherence, and undertreatment at 1 year.

A total of 407 patients (median age 48 years, 56 percent males) were included, of whom 60.2 percent had Crohn’s disease (CD), 54 percent had chronic comorbidity, and 27 percent had multiple comorbidities. The median number of prescriptions per patient was 3 (range, 0‒15). [J Clin Gastroenterol 2022;56:e189-e195]

Of the patients, 18.4 percent had PP, 10.5 percent had inappropriate medication, and 6.1 percent used high-risk medications (mainly opioids).

Multivariate analysis revealed the association of PP with chronic comorbidity (odds ratio [OR], 10.1, 95 percent confidence interval [CI], 2.14‒47.56; p<0.003), multiple comorbidities (OR, 3.53, 95 percent CI, 1.46‒8.51; p=0.005), and age >62 years (OR, 3.54, 95 percent CI, 1.67‒7.51; p=0.001).

At 12 months, PP showed no significant association with poor disease outcomes, but it was the only factor associated with IBD treatment nonadherence (OR, 2.24, 95 percent CI, 1.13‒4.54; p=0.02).

Earlier studies that explored the role of PP in IBD confirmed the prevalence of PP in CD patients and those aged ≥65 years. Vitamins and mineral supplements were the most widely consumed agents, and one of the reasons for the high PP rate was the inclusion of over-the-counter drugs. [Aliment Pharmacol Ther 2005;21:1211-1216; Intest Res 2019;17:496-503; Inflamm Bowel Dis 2015;21:1392-1140]

Comorbidities

“Another important finding in our study is the high prevalence of chronic comorbidity; more than half of patients presented at least 1 associated chronic disease,” the researchers said. “These results are consistent with the Swiss series, in which cardiovascular and metabolic disease were the most prevalent comorbidities.” [Eur J Gastroenterol Hepatol 2017;29:916-925]

In the current series, psychiatric disorders were also present in 13 percent of patients. This finding was consistent with that of a previous systematic review and meta-analysis, which reported pooled mean proportion of 19.1 percent and 21.2 percent for anxiety and depression, respectively. [Inflamm Bowel Dis 2016;22:752-762]

“Importantly, the concomitant presence of these chronic conditions requires the use of some drugs to control symptoms according to clinical guidelines that often do not take into account patients with chronic multimorbidity, contributing to the appearance of drug addiction problems,” the researchers said. [Lancet 2012;380:37-43]

Most used drugs

Analgesics was the most frequently used drug class in the current study, followed by proton pump inhibitors. With pain and discomfort being a common issue among patients, analgesics then became the go-to solution to control them, especially in self-medication. [Pain 2005;115:374-381]

On the other hand, use of PPIs continues to increase across the globe despite well-defined indications. This stresses the need to re-establish the correct use of this drug class. [Eur J Intern Med 2017;45:160-168; Curr Drug Metab 2018;19:142-154]

“As gastroenterologists, it is very important to establish and reassess the indications for PPIs in IBD patients for several reasons, such as some intestinal adverse events, small intestinal bacterial overgrowth, a possible association with the development of microscopic colitis and, finally, the risk of presenting Clostridioides difficile infection,” the researchers said. [Expert Opin Drug Saf 2019;18:1043-1053; Ann Pharmacother 2017;51:253-263; Clin Gastroenterol Hepatol 2012;10:225-233]