Older People's Services - Whipps Cross University Hospital - Barts Health NHS Trust; MRC Unit for Lifelong Health and Ageing - University College of London, United Kingdom.
Univ. Lille, CHU Lille, EA2694 - Evaluation des Technologies de Santé et des Pratiques Médicales, F-59000 Lille, France.
Maturitas. 2019 Jun;124:43-47. doi: 10.1016/j.maturitas.2019.03.007. Epub 2019 Mar 14.
Achieving appropriate medication is a multidimensional process. Current research on polypharmacy mainly focuses on drug appropriateness, but little is devoted to what determines the ongoing challenge. The authors, with their diverse clinical, pharmaceutical and regulatory backgrounds, offer a narrative review on the causes of inappropriate polypharmacy and how to avoid it. Inappropriate polypharmacy may stem from the systematic exclusion of frail older patients from landmark randomised controlled trials, which has prevented the accurate establishment of the clinical benefits of a drug for that ever-growing group of patients. Nonetheless, what may determine the usefulness of a drug in a specific patient cohort is its design. Patient-centric drug product development must, therefore, account for older people's characteristics, so that drugs are better formulated from their inception. This novel drug development process has significant implications for industry and requires adequate regulation. Clinicians must understand and be part of drug development. Explicit criteria such as STOPP/START provide guidance on identifying opportunities and circumstances to review medication but achieving appropriateness is far more complicated. New healthcare technology may pave the way to better-tailored interventions at a healthcare system level, but patient and advocate voices, as well as communication and continuity of care, must remain at the core. In conclusion, inappropriate polypharmacy results from the combination of multiple factors. Achieving appropriate medication for older adults requires merging different disciplines and a focus on patients' needs and expectations.
实现适当的药物治疗是一个多维度的过程。目前关于多种药物治疗的研究主要集中在药物的适当性上，但很少关注决定这一持续挑战的因素。作者具有不同的临床、药学和监管背景，对不适当的多种药物治疗的原因以及如何避免这种情况进行了叙述性综述。不适当的多种药物治疗可能源于将体弱的老年患者系统性地排除在具有里程碑意义的随机对照试验之外，这使得人们无法准确确定药物对这一不断增长的患者群体的临床益处。然而，决定某种药物对特定患者群体是否有用的因素可能是药物的设计。因此，以患者为中心的药物产品开发必须考虑到老年人的特点，从药物研发之初就对其进行更好的设计。这种新的药物开发过程对行业具有重要意义，需要充分的监管。临床医生必须了解并参与药物开发。明确的标准，如 STOPP/START，为识别有机会和情况进行药物审查提供了指导，但实现适当性要复杂得多。新的医疗技术可能为医疗系统层面上更好地定制干预措施铺平道路，但患者和倡导者的声音，以及沟通和护理的连续性，必须仍然是核心。总之，不适当的多种药物治疗是多种因素共同作用的结果。为老年人实现适当的药物治疗需要融合不同的学科，并关注患者的需求和期望。
