Polypharmacy in the heart failure patient: are all prescribed drug classes required?

2017-03-02T02:59:19Z (GMT) by Hopper, Ingrid Kate
Background and aims: Heart failure (HF) is a complex disease process with high mortality and high costs to the community. Major inroads have been made in reducing the high morbidity and mortality associated, largely by the use of drug therapies that focus on key neurohormonal systems activated in HF with demonstrated mortality benefits. Other therapies are also employed in the HF setting that do not have mortality benefits, and contribute to polypharmacy in HF patients. Polypharmacy, defined herein as the use of five or more prescription medications, is increasing in HF patients. This thesis aims to explore the issue of polypharmacy in the HF patient, and whether all prescribed drug classes are required. Methods: A systematic review of the medical literature on drug withdrawal trials was performed to identify which drugs could and could not be withdrawn in HF. Three randomised clinical trials were conducted investigating the effect of withdrawing digoxin, aspirin or statin in stable HF patients. Qualitative methods were used to explore attitudes of clinician prescribers and HF patients to medications, looking in particular at withdrawal of medications. Results: This thesis examined the available data on medication withdrawal in HF patients and translated it into practical recommendations for prescribers; demonstrated that with contemporaneous background HF therapies, withdrawal of digoxin worsens HF clinical status and that withdrawal of statins or aspirin does not; found that HF patients with polypharmacy are largely not dissatisfied with the number of medications they take, and that prescribing clinicians recognise polypharmacy as important but address it infrequently in clinical practice. Conclusions: It is expected that polypharmacy will increase in HF patients. This research provides an evidence base with which clinicians can address polypharmacy in HF in their clinical practice.

Awards: Winner of the Mollie Holman Doctoral Medal for Excellence, Faculty of Medicine, Nursing and Health Science, 2016.