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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, there has been a progressive aging of the population, and with the inverting of the population pyramid, there has been an increase in the number of polypathological patients. This situation requires changes in the healthcare system to address this issue and provide better guarantees.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> The concept of polypathological patients identifies (using objective criteria) a group of patients with homogeneous clinical and healthcare characteristics, with high frailty and considerable complexity in their management.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Elderly polypathological patients usually take numerous long-term prescription drugs (polypharmacy).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although there are numerous definitions of polypharmacy, probably the most widely used in the literature is the consumption of 5 or more drugs daily. Extreme polypharmacy is considered when 10 or more drugs are consumed daily.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> There are interesting studies in Spain that have evaluated the topic of polypharmacy in frail elderly patients with polypathology.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a> In a study that included 672 patients aged 75 years or more hospitalized in the internal medicine departments of 7 Spanish hospitals, 92.4% took 5 or more drugs.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a> Of the included patients, 419 (62%) were polypathological, and 89.3% of them had inappropriate use of medications, compared with 79.4% of the nonpolypathological patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.01). Polypharmacy was the most significant risk factor for the inappropriate use of drugs.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a> The Beers criteria and the STOPP/START (Screening Tool of Older Person's Prescriptions/Screening Tool to Alert Doctors to Right i.e. appropriate indicated Treatment) criteria are probably the 2 most widely instruments for assessing the appropriate use of drugs.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The presence of polypharmacy is associated with a greater risk of therapeutic inadequacy, reduced adherence and increased potential interactions, duplications and contraindications.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In this respect, the potential inadequate use of drugs could be associated with an increase in the onset of adverse effects and to an increase in associated morbidity and mortality. It is therefore important to try to better understand the patient group with polypharmacy and the various drugs employed, to be able to reduce the inappropriate use of drugs and the consequences of their improper use.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6,10</span></a> All this assumes special importance for polypathological patients.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Bellostas-Muñoz and Díez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> published in this issue, goes beyond the concept of polypharmacy and analyzes the complexity of the therapeutic regimen at hospital discharge for polypathological patients hospitalized in the internal medicine departments of 5 hospitals in Aragon of various healthcare levels. To assess the therapeutic complexity, the authors used the Medical Regimen Complexity Index (MRCI),<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> a complete tool whose end value is the sum of numerous parameters divided into 3 sections referencing the galenical form, the posology and the additional instructions associated with taking the drug. The MRCI was calculated based on the data in the discharge report. The drug regimen was considered complex when the MRCI score was in the fourth quartile. This was a study with a comprehensive methodology where the authors analyzed a large number of geriatric indices and scales. The study included 233 polypathological patients with a mean age of 79.8 years, 52.9% of whom were women. The mean number of drugs consumed was high (8.4), and most of the patients presented polypharmacy, while a third showed extreme polypharmacy. The authors concluded that the polypathological patients were polymedicated and had complex therapeutic drug regimens. Respiratory diseases were independently associated with greater therapeutic complexity, and cognitive impairment was associated with lower therapeutic complexity. In the article, the authors recognized a number of limitations that complicate the generalization of the data, although the data serve as an important starting point. Determining whether there were inappropriate prescriptions might have provided interesting information.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Understanding the treatment complexity of our patients is crucial, because it has been related to a poorer prognosis, for example, in terms of poorer treatment adherence, increased risk of hospitalization, higher mortality, nosocomial infections and other complications during hospitalization and the need for institutionalization after hospital discharge.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13–15</span></a> The effort needs to be bidirectional, working toward reducing treatment complexity and, when this is not possible, working to improve treatment adherence, thereby reducing the greater risk of hospitalization. The clinical practice guidelines for treating heart failure and chronic obstructive pulmonary disease, two of the main diagnoses in the study by Bellostas-Muñoz and Díez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and in most internal medicine departments in Spain, recommend using multiple drugs, contributing to these patients’ polypharmacy and complexity.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As stated by the authors, the hospital admission, the typical setting for internists, can represent an appropriate moment to review the treatment indications and regimens of polypathological patients, which obviously should always be added to the patients’ overall assessment. Incorporating the concept of therapeutic complexity, a wider concept than polypharmacy and which Bellostas-Muñoz and Díez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> apply to polypathological patients, will help us better understand these patients. The study of therapeutic complexity should result in benefits for patients in general and polypathological patients in particular, although further studies are necessary to analyze this complexity in other scenarios.</p></span>"
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"nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Riera-Mestre A, Formiga F. Complejidad terapéutica: un nuevo reto. Rev Clin Esp. 2018;218:356–357.</p>"
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