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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; there has been a progressive aging of the population&#44; and with the inverting of the population pyramid&#44; there has been an increase in the number of polypathological patients&#46; This situation requires changes in the healthcare system to address this issue and provide better guarantees&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> The concept of polypathological patients identifies &#40;using objective criteria&#41; a group of patients with homogeneous clinical and healthcare characteristics&#44; with high frailty and considerable complexity in their management&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Elderly polypathological patients usually take numerous long-term prescription drugs &#40;polypharmacy&#41;&#46;<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&#44; probably the most widely used in the literature is the consumption of 5 or more drugs daily&#46; Extreme polypharmacy is considered when 10 or more drugs are consumed daily&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;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&#44; 92&#46;4&#37; took 5 or more drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6</span></a> Of the included patients&#44; 419 &#40;62&#37;&#41; were polypathological&#44; and 89&#46;3&#37; of them had inappropriate use of medications&#44; compared with 79&#46;4&#37; of the nonpolypathological patients &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; Polypharmacy was the most significant risk factor for the inappropriate use of drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6</span></a> The Beers criteria and the STOPP&#47;START &#40;Screening Tool of Older Person&#39;s Prescriptions&#47;Screening Tool to Alert Doctors to Right i&#46;e&#46; appropriate indicated Treatment&#41; criteria are probably the 2 most widely instruments for assessing the appropriate use of drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The presence of polypharmacy is associated with a greater risk of therapeutic inadequacy&#44; reduced adherence and increased potential interactions&#44; duplications and contraindications&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In this respect&#44; 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&#46; It is therefore important to try to better understand the patient group with polypharmacy and the various drugs employed&#44; to be able to reduce the inappropriate use of drugs and the consequences of their improper use&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6&#44;10</span></a> All this assumes special importance for polypathological patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Bellostas-Mu&#241;oz and D&#237;ez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> published in this issue&#44; 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&#46; To assess the therapeutic complexity&#44; the authors used the Medical Regimen Complexity Index &#40;MRCI&#41;&#44;<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&#44; the posology and the additional instructions associated with taking the drug&#46; The MRCI was calculated based on the data in the discharge report&#46; The drug regimen was considered complex when the MRCI score was in the fourth quartile&#46; This was a study with a comprehensive methodology where the authors analyzed a large number of geriatric indices and scales&#46; The study included 233 polypathological patients with a mean age of 79&#46;8 years&#44; 52&#46;9&#37; of whom were women&#46; The mean number of drugs consumed was high &#40;8&#46;4&#41;&#44; and most of the patients presented polypharmacy&#44; while a third showed extreme polypharmacy&#46; The authors concluded that the polypathological patients were polymedicated and had complex therapeutic drug regimens&#46; Respiratory diseases were independently associated with greater therapeutic complexity&#44; and cognitive impairment was associated with lower therapeutic complexity&#46; In the article&#44; the authors recognized a number of limitations that complicate the generalization of the data&#44; although the data serve as an important starting point&#46; Determining whether there were inappropriate prescriptions might have provided interesting information&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Understanding the treatment complexity of our patients is crucial&#44; because it has been related to a poorer prognosis&#44; for example&#44; in terms of poorer treatment adherence&#44; increased risk of hospitalization&#44; higher mortality&#44; nosocomial infections and other complications during hospitalization and the need for institutionalization after hospital discharge&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13&#8211;15</span></a> The effort needs to be bidirectional&#44; working toward reducing treatment complexity and&#44; when this is not possible&#44; working to improve treatment adherence&#44; thereby reducing the greater risk of hospitalization&#46; The clinical practice guidelines for treating heart failure and chronic obstructive pulmonary disease&#44; two of the main diagnoses in the study by Bellostas-Mu&#241;oz and D&#237;ez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and in most internal medicine departments in Spain&#44; recommend using multiple drugs&#44; contributing to these patients&#8217; polypharmacy and complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As stated by the authors&#44; the hospital admission&#44; the typical setting for internists&#44; can represent an appropriate moment to review the treatment indications and regimens of polypathological patients&#44; which obviously should always be added to the patients&#8217; overall assessment&#46; Incorporating the concept of therapeutic complexity&#44; a wider concept than polypharmacy and which Bellostas-Mu&#241;oz and D&#237;ez-Manglano<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> apply to polypathological patients&#44; will help us better understand these patients&#46; The study of therapeutic complexity should result in benefits for patients in general and polypathological patients in particular&#44; although further studies are necessary to analyze this complexity in other scenarios&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Riera-Mestre A&#44; Formiga F&#46; Complejidad terap&#233;utica&#58; un nuevo reto&#46; Rev Clin Esp&#46; 2018&#59;218&#58;356&#8211;357&#46;</p>"
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DOI: 10.1016/j.rceng.2018.06.006
Medication regimen complexity: A new challenge
Complejidad terapéutica: un nuevo reto
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A. Riera-Mestrea,b,
Corresponding author
ariera@bellvitgehospital.cat

Corresponding author.
, F. Formigab,c
a Servicio de Medicina Interna, Hospital Universitari de Bellvitge – IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
b Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain
c Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge - IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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