Polypharmacy, or the use of five or more medications, is rampant among the population undergoing dialysis. Patients on dialysis in the United States take a median of 19 pills per day from 11 different prescriptions (1). Polypharmacy is associated with non-adherence from 13% to 99% of patients on dialysis (2), as well as with medication errors and adverse drug events (3), financial strain (4), and lower health-related quality of life (1). However, until a recent article in Kidney Medicine by Colombijn et al. (5), no studies, to our knowledge, had evaluated the patient's perspective on how polypharmacy impacts their well-being. Unfortunately, their results were bleak: patients on dialysis find their medications to be a burdensome but necessary evil.
Colombijn and colleagues (5) interviewed 28 individuals on in-center hemodialysis or peritoneal dialysis in the Netherlands about their experiences with polypharmacy. They quickly learned that the participants had varied definitions of “medicine,” especially regarding vitamins, binders, laxatives, creams, and herbal preparations. They found that most participants “were well aware of which medications they were taking,” reported good adherence, and developed unique routines to remember to take them.
Participants perceived their medications as burdensome but had resigned themselves to taking them. They associated their medications with “garbage,” shame, and dependency. Participants felt they took “a lot” of medication and wished they could take fewer. Many participants did not notice the efficacy of their medications (or dialysis for that matter) and had more favorable perceptions of the medications that provided symptom relief. Even worse, the participants noted that several of their medications triggered unpleasant physical reactions (from difficulty swallowing to myriad side effects). Dishearteningly, the authors note that these experiences with polypharmacy echo those of recipients of kidney transplant (6) and patients not on dialysis (7), but the patients on dialysis “take the burden of polypharmacy relatively lightly because the burden of medication pales in comparison to dialysis.”
Participants did emphasize that not taking their medication would lead to their health worsening, which was not in line with their goals. The realization that their medications are important for their health helped mitigate the negative impact of polypharmacy on their quality of life. The investigators explored this thread further to identify ways that health care clinicians could help with patients’ medication regimen. Practical tips for doing so are outlined in Table 1.
Practical recommendations for managing polypharmacy in patients receiving dialysis
As qualitative studies are beginning to garner more weight in medicine, it is important to note the aspirational methods that Colombijn and colleagues (5) used. The interviewers had no personal relationship with the participants, dialysis, or polypharmacy, and all but one of the interviewers had a background in cultural anthropology (i.e., they were experts at a scientific interview). The participants chose the interview location, allowing for privacy, convenience, and rapport. The data were analyzed starting with the interviews rather than a preconceived framework to identify themes.
Although every qualitative study is limited by generalizability, there can be no doubt that polypharmacy negatively affects patients’ quality of life. Further studies will develop strategies to improve a patient's experience of medication and allow for effective prescribing and de-prescribing to limit polypharmacy.
Footnotes
References
- 1.↑
Chiu YW, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol 2009; 4:1089–1096. doi: 10.2215/CJN.00290109
- 2.↑
Ghimire S, et al. Nonadherence to medication therapy in haemodialysis patients: A systematic review. PLoS One 2015; 10:e0144119. doi: 10.1371/journal.pone.0144119
- 3.↑
Manley HJ, et al. Medication-related problems in ambulatory hemodialysis patients: A pooled analysis. Am J Kidney Dis 2005; 46:669–680. doi: 10.1053/j.ajkd.2005.07.001
- 4.↑
Gedney N. The impact of medication cost on dialysis patients. Kidney360 2021; 2:922–923. doi: 10.34067/KID.0002162021
- 5.↑
Colombijn JMT, et al. Polypharmacy and quality of life among dialysis patients: A qualitative study. Kidney Med 2023; 6:100749. doi: 10.1016/j.xkme.2023.100749
- 6.↑
Tong A, et al. The perspectives of kidney transplant recipients on medicine taking: A systematic review of qualitative studies. Nephrol Dial Transplant 2011; 26:344–354. doi: 10.1093/ndt/gfq376
- 7.↑
Eriksen CU, et al. Medication-related experiences of patients with polypharmacy: A systematic review of qualitative studies. BMJ Open 2020; 10:e036158. doi: 10.1136/bmjopen-2019-036158