Higher pill burden decreases compliance with drug therapy, due to the need to take a large quantity of pills on a regular basis. It also increases the possibility of adverse medication reactions ("side effects") and drug-drug interactions due to polypharmacy. High pill burden has also been associated with increased risk of hospitalization, medication errors, and increased costs both for the pharmaceuticals involved and for the treatment of adverse events. Finally, it is source of dissatisfaction to many patients.
High pill burden is commonly associated with antiretroviral drug regimens to control HIV, but can be seen in other patient populations. For instance, an adult with multiple chronic conditions such as diabetes, hypertension, hypercholesterolemia, osteoporosis, constipation and clinical depression can often be prescribed more than a dozen different medications daily. Obesity is implicated in many of the aforementioned conditions, and it is not uncommon for a clinically obese patient to receive pharmacologic treatment for all of these. Because chronic conditions tend to accumulate in the elderly, pill burden is a particular issue in geriatrics.
Reducing pill burden is recognized as a way to improve medication compliance. Common approaches to reducing pill burden may include selecting fixed dose combination drug products, products with long-acting active ingredients, and sustained release/extended release formulations when appropriate.
Some combinations of drugs may be available in certain strengths as a single pill, called a fixed dose combination. One notable example of a fixed dose combination drug product is the antiretroviral drug product Atripla, which combines 3 drugs (efavirenz + emtricitabine + tenofovir) into one pill.
The selection of long-acting active ingredients over short-acting ones may also reduce pill burden. For instance, ACE inhibitors are used in the management of hypertension. Both captopril and lisinopril are examples of ACE inhibitors. However, lisinopril is dosed once a day, whereas captopril may be dosed 2-3 times a day. Assuming that there are no contraindications or potential for drug interactions, using lisinopril instead of captopril may be an appropriate way to limit pill burden.
Similarly, sustained release/extended release drug formulations reduce pill burden by reducing the dosing frequency. The same active ingredient is present in both the immediate-release form and the sustained release form.
Many medications have potential interactions with other substances. As a new drug is prescribed, the risk of interactions increases exponentially. Doctors and pharmacists aim to avoid prescribing medications that interact; often, adjustments in the dose of medications need to be made to avoid interactions, such as with warfarin, as it may lose its effect.
A patient with a complex or even an ostensibly straight forward illness whose personal pharmacopoeia reads like a drug store pharmacy is not necessarily receiving poor treatment. A carefully followed patient with whom a physician is using additive drug choice and dosage range on a trial and error basis may lead to a treatment program that, for a real example, includes two antidepressants, three antihypertensives, a beta blocker, a calcium channel blocker, a bone saving bisphosphonate, an antiepileptic, a stomach saving H2 blocker, aspirin, prostaglandin blocker, lactoferrin, a calcium-magnesium supplement and herbal preparations.
Two generally true circumstances underlie the theory of thoughtful, therapeutic polypharmacy: (1) Drugs given for a single somatic locale act on biochemical mechanisms present throughout the body such that their nonlinear interactions can produce an (unknown except empirically) global physiological state of health; (2) The more independent variables, "handles", to manipulate, the greater the likelihood of finding and stabilizing a small available parametric space of healthy function while minimizing unwanted effects.