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Kim S, Lee H, Park J, Kang J, Rahmati M, Rhee SY, Yon DK. Global and regional prevalence of polypharmacy and related factors, 1997-2022: An umbrella review. Arch Gerontol Geriatr 2024; 124:105465. [PMID: 38733922 DOI: 10.1016/j.archger.2024.105465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE Limited comprehensive evidence exists on the global prevalence of polypharmacy. This knowledge gap contributes to increased healthcare system costs and related public health concerns. Thus, we aimed to synthesize the current evidence on polypharmacy prevalence and associated factors in the general and older populations using an umbrella review. METHODS Our primary outcomes were global prevalence and related indicators of polypharmacy. We systematically searched Google Scholar, PubMed/MEDLINE, Embase, and CINAHL for studies published between the inception of each database until April 30, 2023. RESULTS Eleven meta-analyses incorporating 295 studies and 59,552,762 participants from 41 countries across six continents were identified. The global prevalence of polypharmacy in the general population is 37 %, with higher rates in older individuals (45 %), outpatients (48 %), and inpatients (52 %). North America showed a higher prevalence (52 %) than Asia (36 %) and Europe (36 %). Among frail elderly individuals, the prevalence of polypharmacy is 59 %, with the highest rates in Europe (68 %) and hospital settings (71 %). CONCLUSION The global prevalence of polypharmacy and its associated factors in older adults present a complex, multifaceted, and conflicting picture. Understanding the prevalence of polypharmacy and its associated factors may help reduce the number of multidrug prescriptions.
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Affiliation(s)
- Sunyoung Kim
- Department of Family Medicine, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, South Korea.
| | - Hyeri Lee
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea; Department of Regulatory Science, Kyung Hee University, Seoul, South Korea
| | - Jaeyu Park
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea; Department of Regulatory Science, Kyung Hee University, Seoul, South Korea
| | - Jiseung Kang
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Masoud Rahmati
- Research Centre on Health Services and Quality of Life, Aix Marseille University, Marseille, France; Department of Physical Education and Sport Sciences, Faculty of Literature and Human Sciences, Lorestan University, Khoramabad, Iran; Department of Physical Education and Sport Sciences, Faculty of Literature and Humanities, Vali-E-Asr University of Rafsanjan, Rafsanjan, Iran
| | - Sang Youl Rhee
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea; Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea; Department of Regulatory Science, Kyung Hee University, Seoul, South Korea; Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, South Korea.
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Biso L, Aringhieri S, Carli M, Scarselli M, Longoni B. Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes. Pharmaceuticals (Basel) 2024; 17:642. [PMID: 38794212 PMCID: PMC11124530 DOI: 10.3390/ph17050642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
Psychiatric disorders often require pharmacological interventions to alleviate symptoms and improve quality of life. However, achieving an optimal therapeutic outcome is challenging due to several factors, including variability in the individual response, inter-individual differences in drug metabolism, and drug interactions in polytherapy. Therapeutic drug monitoring (TDM), by measuring drug concentrations in biological samples, represents a valuable tool to address these challenges, by tailoring medication regimens to each individual. This review analyzes the current landscape of TDM in psychiatric practice, highlighting its significance in optimizing drug dosages, minimizing adverse effects, and improving therapeutic efficacy. The metabolism of psychiatric medications (i.e., mood stabilizers, antipsychotics, antidepressants) often exhibits significant inter-patient variability. TDM can help address this variability by enhancing treatment personalization, facilitating early suboptimal- or toxic-level detection, and allowing for timely interventions to prevent treatment failure or adverse effects. Furthermore, this review briefly discusses technological advancements and analytical methods supporting the implementation of TDM in psychiatric settings. These innovations enable quick and cost-effective drug concentration measurements, fostering the widespread adoption of TDM as a routine practice in psychiatric care. In conclusion, the integration of TDM in psychiatry can improve treatment outcomes by individualizing medication regimens within the so-called precision medicine.
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Affiliation(s)
- Letizia Biso
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Stefano Aringhieri
- Mental Health and Pathological Addiction Department, AUSL Romagna Forlì-Cesena, 47121 Forlì, Italy;
| | - Marco Carli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Marco Scarselli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Biancamaria Longoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
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Kraus J, Čavojská N, Harvanová S, Hajdúk M. Interpersonal distance in schizophrenia: A systematic review. Schizophr Res 2024; 266:1-11. [PMID: 38359513 DOI: 10.1016/j.schres.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND HYPOTHESIS Schizophrenia is often associated with severe difficulties in social functioning, resulting in increased isolation and subsequent loneliness. Interpersonal distance - the amount of space around an individual's body during social interaction - can signal such difficulties. However, little is known about how individuals with schizophrenia regulate their interpersonal distance during social encounters. Summarizing the current empirical findings of interpersonal distance regulation in schizophrenia can bring novel perspectives for understanding interpersonal difficulties observed in this clinical population. STUDY DESIGN This systematic review examined empirical studies indexed in Web of Science and PubMed based on a-priori-defined criteria. 1164 studies were screened with the final review consisting of 14 studies. They together included 1145 adult participants, of whom 668 were diagnosed with schizophrenia or psychotic disorder. STUDY RESULTS The studies clearly showed that patients maintain greater interpersonal distances than do controls. Furthermore, a larger distance was linked to more severe positive and negative symptoms. More specifically, the link to symptoms was more pronounced when patients were being approached by someone else during interactions. On a neurobiological level, the increased activity and functional connectivity of the dorsal inferior parietal sulcus and increased subjective state-dependent stress are further indicated as being potentially related to increase interpersonal distancing in schizophrenia. CONCLUSIONS We provided information about the aberrant modulation of interpersonal distance in schizophrenia. Studies showed substantial heterogeneity in tasks used to measure interpersonal distance. Future studies should look at links to social functioning, underlying neurobiology, and neuroendocrinal regulation of interpersonal space in schizophrenia.
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Affiliation(s)
- Jakub Kraus
- Department of Psychology, Faculty of Arts, Comenius University in Bratislava, Slovakia; Centre for Psychiatric Disorders Research, Science Park, Comenius University in Bratislava, Slovakia.
| | - Natália Čavojská
- Centre for Psychiatric Disorders Research, Science Park, Comenius University in Bratislava, Slovakia; Department of Psychiatry, Faculty of Medicine, Comenius University in Bratislava, Slovakia
| | - Silvia Harvanová
- Department of Psychology, Faculty of Arts, Comenius University in Bratislava, Slovakia
| | - Michal Hajdúk
- Department of Psychology, Faculty of Arts, Comenius University in Bratislava, Slovakia; Centre for Psychiatric Disorders Research, Science Park, Comenius University in Bratislava, Slovakia; Department of Psychiatry, Faculty of Medicine, Comenius University in Bratislava, Slovakia
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Tamene FB, Sema FD, Sendekie AK. Antipsychotic polypharmacy and associated factors among patients with schizophrenia: Multicenter cross-sectional study in Northwest Ethiopia. PLoS One 2023; 18:e0290037. [PMID: 37578965 PMCID: PMC10424862 DOI: 10.1371/journal.pone.0290037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) remains common despite guideline recommendations to minimize combinations, except after repeated antipsychotic monotherapy trials. This study aimed to assess APP and its associated factors among schizophrenia patients at comprehensive specialized hospitals in Northwest Ethiopia. METHODS An institutional-based cross-sectional study was conducted among 422 schizophrenia patients at selected hospitals in Ethiopia from June to August 2022. The data were collected using a semi-structured questionnaire. Study participants were enrolled using systematic random sampling. Data entry and analysis were done with Epi-data version 4.6.1 and SPSS version 24, respectively. APP was determined by reviewing the number of medications based on relevant evidence. A multivariable logistic regression model was fitted to identify APP factors. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant. RESULTS From a total of 430 approached samples, 422 (98.1% response rate) eligible patients were included in the study. An overall APP prevalence was 22.7% (95% CI: 19-27). Duration of illness (AOR = 2.88; 95% CI: 1.49, 5.59); duration of treatment (AOR = 3.79; 95% CI: 1.05, 13.62); number of admissions (AOR = 4.93; 95% CI: 2.52, 9.64); and substance use (AOR = 2.58; 95% CI: 1.49, 4.47) were significantly associated with APP. CONCLUSION AND RECOMMENDATION In this study, APP was recorded in a considerable number of patients. Patients with a longer duration of illness and treatment, frequent admissions, and substance users need critical follow-up to minimize antipsychotic medication use.
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Affiliation(s)
- Fasil Bayafers Tamene
- Clinical Pharmacy Unit, Pharmacy Department, Health Science College, Debre Markos University, Debre Markos, Ethiopia
| | - Faisel Dula Sema
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ashenafi Kibret Sendekie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Ochi S, Tagata H, Hasegawa N, Yasui-Furukori N, Iga JI, Kashiwagi H, Kodaka F, Komatsu H, Tsuboi T, Tokutani A, Numata S, Ichihashi K, Onitsuka T, Muraoka H, Iida H, Ohi K, Atake K, Kishimoto T, Hori H, Takaesu Y, Takeshima M, Usami M, Makinodan M, Hashimoto N, Fujimoto M, Furihata R, Nagasawa T, Yamada H, Matsumoto J, Miura K, Kido M, Hishimoto A, Ueno SI, Watanabe K, Inada K, Hashimoto R. Clozapine Treatment Is Associated With Higher Prescription Rate of Antipsychotic Monotherapy and Lower Prescription Rate of Other Concomitant Psychotropics: A Real-World Nationwide Study. Int J Neuropsychopharmacol 2022; 25:818-826. [PMID: 35723038 PMCID: PMC9593218 DOI: 10.1093/ijnp/pyac036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although clozapine is effective for treatment-resistant schizophrenia (TRS), the rate of clozapine prescription is still low. Whereas antipsychotic monotherapy is recommended in clinical practice guidelines, the rate of antipsychotic polypharmacy is still high. There is little evidence on whether a clozapine prescription influences changes in the rate of monotherapy and polypharmacy, including antipsychotics and other psychotropics. We therefore hypothesized that the rate of antipsychotic monotherapy in patients with TRS who were prescribed clozapine would be higher than that in patients with schizophrenia who were not prescribed clozapine. METHODS We assessed 8306 patients with schizophrenia nationwide from 178 institutions in Japan from 2016 to 2019. We analyzed the psychotropic prescription data at discharge in patients diagnosed with TRS and with no description of TRS (ND-TRS) based on the diagnosis listed in the discharge summary. RESULTS The rate of antipsychotic monotherapy in the TRS with clozapine group (91.3%) was significantly higher than that in the TRS without clozapine group (45.9%; P < 2.0 × 10-16) and the ND-TRS without clozapine group (54.7%; P < 2.0 × 10-16). The rate of antipsychotic monotherapy without any other concomitant psychotropics in the TRS with clozapine group (26.5%) was significantly higher than that in the TRS without clozapine group (12.6%; P = 1.1 × 10-6) and the ND-TRS without clozapine group (17.0%; P = 5.9 × 10-6). CONCLUSIONS Clozapine prescription could be associated with a high rate of antipsychotic monotherapy. Patients will benefit from the correct diagnosis of TRS and thus from proper clozapine prescription.
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Affiliation(s)
- Shinichiro Ochi
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiromi Tagata
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Naomi Hasegawa
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Norio Yasui-Furukori
- Correspondence: Norio Yasui-Furukori, MD, PhD, Department of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Shimotsuga, Mibu, Tochigi, 321-0293, Japan ()
| | - Jun-ichi Iga
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroko Kashiwagi
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Forensic Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Fumitoshi Kodaka
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japsan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Miyagi, Japan
| | - Takashi Tsuboi
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Akira Tokutani
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Hyogo, Japan
| | - Shusuke Numata
- Department of Psychiatry, Graduate School of Biomedical Science, Tokushima University, Tokushima, Japan
| | - Kayo Ichihashi
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Toshiaki Onitsuka
- Department of Neuroimaging Psychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Muraoka
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hitoshi Iida
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kiyokazu Atake
- Nippon Telegraph and Telephone West Corporation Kyushu Health Administration Center, Fukuoka, Japan
| | - Taishiro Kishimoto
- Hills Joint Research Laboratory for Future Preventive Medicine and Wellness, Keio University School of Medicine, Tokyo, Japan
| | - Hikaru Hori
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Masahide Usami
- Department of Child and Adolescent Psychiatry, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Manabu Makinodan
- Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan
| | - Naoki Hashimoto
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Michiko Fujimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Tatsuya Nagasawa
- Department of NeuroPsychiatry Kanazawa Medical University, Ishikawa, Japan
| | - Hisashi Yamada
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Neuropsychiatry, Hyogo College of Medicine, Hyogo, Japan
| | - Junya Matsumoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kenichiro Miura
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mikio Kido
- Toyama City Hospital, Toyama, Japan,Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Akitoyo Hishimoto
- Department of Psychiatry, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Shu-ichi Ueno
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Ryota Hashimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
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Interventions for adolescents and adults with psychosis in Africa: a systematic review and narrative synthesis. Glob Ment Health (Camb) 2022; 9:223-240. [PMID: 36618745 PMCID: PMC9806991 DOI: 10.1017/gmh.2022.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The Global Burden of Disease attributable to psychotic disorders in African countries is high and has increased sharply in recent years. Yet, there is a scarcity of evidence on effective, appropriate and acceptable interventions for schizophrenia and other psychotic disorders on the continent. METHODS We carried out a systematic review and narrative synthesis of peer-reviewed literature evaluating the impact of non-pharmacological interventions for adolescents and adults (10-65 years) in African countries. Two reviewers independently double-screened all articles and performed data extraction and quality appraisal using standardized tools. RESULTS Of the 8529 unique texts returned by our search, 12 studies were identified for inclusion, from seven countries: Egypt, Ethiopia, Ghana, Kenya, Nigeria, South Africa and Sudan. They evaluated a range of interventions with one or more clinical, psychological or psychosocial, education or awareness or traditional or faith-based components, and were delivered by either mental health specialists or non-specialist health workers. Ten of the 12 included studies reported significant, positive effects on a range of outcomes (including functioning, symptoms and stigma). Nearly half of the interventions were based out of health facilities. Based on quality appraisals, confidence in these studies' findings is only rated low to medium. CONCLUSION Further research is needed to develop and evaluate interventions that meet the diverse needs of people with psychosis, within and beyond the health sector.
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Nwanaji-Enwerem JC, Boyer EW, Olufadeji A. Polypharmacy Exposure, Aging Populations, and COVID-19: Considerations for Healthcare Providers and Public Health Practitioners in Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10263. [PMID: 34639561 PMCID: PMC8507838 DOI: 10.3390/ijerph181910263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022]
Abstract
Given the continent's growing aging population and expanding prevalence of multimorbidity, polypharmacy is an increasingly dire threat to the health of persons living in Africa. The COVID-19 pandemic has only exacerbated these issues. Widespread misinformation, lack of vaccine access, and attempts to avoid being infected have resulted in increases in Africans' willingness to take multiple prescription and nonprescription medications and supplements. Issues with counterfeit pharmaceuticals and the relatively new recognition of emergency medicine as a specialty across the continent also create unique challenges for addressing this urgent public health need. Experts have called for more robust pharmaceutical regulation and healthcare/public health infrastructure investments across the continent. However, these changes take time, and more near-term strategies are needed to mitigate current health needs. In this commentary, we present a nonexhaustive set of immediately implementable recommendations that can serve as local strategies to address current polypharmacy-related health needs of Africans. Importantly, our recommendations take into consideration that not all healthcare providers are emergency medicine trained and that local trends related to polypharmacy will change over time and require ever-evolving public health initiatives. Still, by bolstering training to safeguard against provider availability biases, practicing evidence-based prescribing and shared decision making, and tracking and sharing local trends related to polypharmacy, African healthcare providers and public health practitioners can better position themselves to meet population needs. Furthermore, although these recommendations are tailored to Africans, they may also prove useful to providers and practitioners in other regions facing similar challenges.
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Affiliation(s)
- Jamaji C. Nwanaji-Enwerem
- Gangarosa Department of Environmental Health, Emory Rollins School of Public Health, Atlanta, GA 30322, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Edward W. Boyer
- Department of Emergency Medicine, Division of Medical Toxicology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Ayobami Olufadeji
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Harvard Medical School, Boston, MA 02215, USA;
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