Polypharmacy: a challenge for the primary health care of the Brazilian Unified Health System

Nascimento, Renata Cristina Rezende Macedo do; Álvares, Juliana; Guerra Junior, Augusto Afonso; Gomes, Isabel Cristina; Silveira, Micheline Rosa; Costa, Ediná Alves; Leite, Silvana Nair; Costa, Karen Sarmento; Soeiro, Orlando Mario; Guibu, Ione Aquemi; Karnikowski, Margô Gomes de Oliveira; Acurcio, Francisco de Assis

doi:10.11606/S1518-8787.2017051007136

person Renata Cristina Rezende Macedo do Nascimento

schoolPrograma de Pós-Graduação em Medicamentos e Assistência Farmacêutica. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Juliana Álvares

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Augusto Afonso Guerra Junior

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Isabel Cristina Gomes

schoolFaculdade de Ciências Médicas. Belo Horizonte, MG, Brasil

person Micheline Rosa Silveira

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Ediná Alves Costa

schoolInstituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil

person Silvana Nair Leite

schoolDepartamento de Ciências Farmacêuticas. Universidade Federal de Santa Catarina. Florianópolis, SC, Brasil

person Karen Sarmento Costa

schoolNúcleo de Estudos de Políticas Públicas. Universidade Estadual de Campinas. Campinas, SP, BrasilschoolPrograma de Pós-Graduação em Saúde Coletiva. Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Universidade Estadual de Campinas. Campinas, SP, Brasilschool Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil

person Orlando Mario Soeiro

schoolFaculdade de Ciências Farmacêuticas. Pontifícia Universidade Católica de Campinas. Campinas, SP, Brasil

person Ione Aquemi Guibu

schoolDepartamento de Saúde Coletiva. Faculdade de Ciências Médicas. Santa Casa de São Paulo. São Paulo, SP, Brasil

person Margô Gomes de Oliveira Karnikowski

schoolFaculdade de Ceilândia. Universidade de Brasília. Brasília, DF, Brasil

person Francisco de Assis Acurcio

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

Correspondence: Renata Cristina Rezende Macedo do Nascimento. Universidade Federal de Minas Gerais. Av. Presidente Antônio Carlos, 6627. 31.270-901 Belo Horizonte, MG, Brasil. E-mail:
recmacedo@gmail.com

Authors’ Contribution: All authors contributed substantially in the design and planning of the study. RCRMN contributed to data analysis and interpretation and to the writing of the final version of the manuscript. ICG contributed to data analysis and interpretation. JA, FAA, and AAG Jr. coordinated the research and contributed to the discussion of the structure of the article and to the writing of the final version of the manuscript. MRS, EAC, OMS, SNL, KSC, MGOK, and IAG contributed to the discussion of the structure of the article; to the critical review of the content; and to the approval of the final version of the manuscript. All authors declare to be responsible for all aspects of the study, ensuring its accuracy and completeness.

Conflict of Interest: KSC declares conflict of interest for being former director of the Brazilian Ministry of Health, the research funding institution. The other authors declare no conflict of interest.

Programa de Pós-Graduação em Medicamentos e Assistência Farmacêutica. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

Faculdade de Ciências Médicas. Belo Horizonte, MG, Brasil

Instituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil

Departamento de Ciências Farmacêuticas. Universidade Federal de Santa Catarina. Florianópolis, SC, Brasil

Núcleo de Estudos de Políticas Públicas. Universidade Estadual de Campinas. Campinas, SP, Brasil

Programa de Pós-Graduação em Saúde Coletiva. Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Universidade Estadual de Campinas. Campinas, SP, Brasil

Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil

Faculdade de Ciências Farmacêuticas. Pontifícia Universidade Católica de Campinas. Campinas, SP, Brasil

Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Santa Casa de São Paulo. São Paulo, SP, Brasil

Faculdade de Ceilândia. Universidade de Brasília. Brasília, DF, Brasil

Variable	Number of medicines						p

	1 (n = 2,561)		2–4 (n = 3,340)		5 or more (n = 610)

	n*	% (95%CI)	n*	% (95%CI)	n*	% (95%CI)
Gender							0.146
Female	1,922	74.7 (71.8–77.5)	2,610	76.7 (74.2–79.0)	492	79.9 (75.2–83.9)
Male	639	25.3 (22.5–28.2)	730	23.3 (21.0–25.8)	118	20.1 (16.1–24.8)
Age (years)							< 0.001
18–44	1,541	58.8 (55.9–61.7)	1.266	35.7 (32.2–39.2)	64	12.3 (8.8–17.0)
45–64	746	30.7 (28.2–33.3)	1.414	43.5 (41.3–45.8)	339	54.8 (49.0–60.5)
≥ 65	240	10.4 (8.6–12.6)	640	20.8 (18.1–23.9)	207	32.9 (28.2–38.0)
Marital status							< 0.001
Married/commom-law marriage	1,608	64.2 (61.5–66.9)	2.058	66.4 (64.1–68.7)	350	64.6 (58.5–70.3)
Single	686	24.5 (22.0–27.2)	718	17.2 (15.5–19.0)	70	9.1 (6.7–12.2)
Others	267	11.3 (9.6–13.2)	564	16.3 (14.5–18.3)	190	26,3 (21.2–32.1)
Educational level							< 0.001
Illiterate	187	8.4 (6.7–10.5)	349	11.9 (9.1–15.5)	112	18.5 (13.4–24.9)
Some elementary or middle school	857	37,9 (34,6–41,3)	1,344	44.7 (40.2–49.2)	309	54.7 (47.1–62.1)
Elementary or middle school	348	13.7 (10.9–17.2)	416	12.1 (9.9–14.6)	71	10.9 (7.6–15.3)
High school	964	33.0 (30.1–36.0)	993	25.5 (22.4–28.9)	96	13.3 (9.8–17.8)
Higher education	205	6.9 (5.5–8.7)	238	5.8 (4.7–7.2)	22	2.6 (1.5–4.4)
Economic class							0.844
A or B	443	16.0 (13.2–19.2)	532	14.7 (12.2–17.7)	97	14.1 (9.8–19.7)
C	1,488	54.6 (50.7–58.4)	1,954	54.5 (50.6–58.4)	348	54.0 (48.7–59.3)
D or F	627	29.5 (24.7–34.7)	853	30.7 (25.6–36.4)	165	31.9 (25.0–39.7)
Country region							< 0.001
North	491	6.2 (4.7–8.2)	522	4.7 (3.5–6.3)	26	1.2 (0.7–2.3)
Northeast	483	29.4 (21.5–38.6)	621	29.9 (21.5–39.8)	75	22.1 (13.8–33.5)
Midwest	507	7.1 (5.3–9.6)	461	4.4 (2.9–6.7)	77	3.5 (1.6–7.5)
Southeast	571	36.6 (28.3–45.7)	694	32.6 (23.4–43.3)	119	27.2 (18.1–38.9)
South	494	20.7 (16.2–26.1)	891	28.4 (20.2–38.4)	275	45.9 (34.4–61.0)
Has health insurance (yes)	215	9.0 (6.6–12.1)	300	9.5 (6.7–13.3)	89	17.0 (11.5–24.5)	0.001

Variable	Number of Medicines						p

	1 (n = 2,561)		2–4 (n = 3,340)		5 or more (n = 610)

	n^a	% (95%CI)	n^a	% (95%CI)	n^a	% (95%CI)
Alcohol use (yes)^b	339	12.9 (11.0–15.1)	343	9.4 (7.9–11.1)	40	5.9 (3.8–9.1)	< 0.001
Smoking (yes)	319	13.2 (11.6–15.0)	405	13.4 (11.5–15.5)	87	14.7 (10.6–20.1)	0.783
Practice of physical activity (yes)^c	662	23.6 (20.5–27.0)	924	27.9 (24.0–32.2)	184	29.6 (24.7–35.0)	0.007
Self-perception of health							< 0.001
Very good/good	1,645	63.0 (59.2–66.5)	1,613	48.5 (44.8–52.2)	173	25.7 (21.8–30.2)
Neither bad/nor good	777	31.7 (29.2–34.3)	1,388	41.9 (39.0–44.9)	307	51.1 (45.3–56.9)
Bad/very bad	135	5.4 (3.8–7.5)	334	9.6 (8.1–11.3)	129	23.2 (18.5–28.6)
Number of chronic diseases							< 0.001
None	1,036	39.0 (36.0–42.2)	550	24.8 (22.1–27.7)	8	1.0 (0.4–2.5)
One	840	36.5 (33.4–39.7)	792	24.8 (22.1–27.7)	30	27.2 (25.5–29.1)
Two or more	595	24.5 (22.1–27.0)	1,846	60.6 (55.9–65.0)	532	95.1 (92.1–97.0)
Main chronic diseases							< 0.001
Hypertension	642	28.1 (25.1–31.4)	1,787	56.6 (51.6–61.4)	510	84.3 (79.9–87.9)
Dyslipidemia	367	14.4 (12.5–16.6)	1,036	31.6 (28.5–34.9)	338	57.8 (51.8–63.6)
Arthritis, arthrosis, or rheumatism	293	12.4 (10.4–14.6)	896	26.5 (23.2–30.1)	306	51.3 (44.8–57.7)
Depression	281	12.2 (10.5–14.2)	784	24.5 (21.5–27.9)	277	47.3 (40.9–53.9)
Diabetes mellitus	154	5.4 (4.5–6.5)	653	21.1 (17.6–25.0)	270	41.6 (36.6–46.8)
Heart diseases	99	3.4 (2.4–4.7)	300	9.9 (8.1–12.1)	198	33.3 (27.0–40.3)
Chronic pulmonary disease	210	8.4 (6.9–10.1)	401	10.7 (9.0–12.6)	121	18.5 (14.4–23.5)
Stroke	29	1.4 (0.8–2.2)	111	3.3 (2.4–4.4)	60	8.7 (6.2–12.1)
Other diseases	396	15.1 (12.5–18.2)	760	23.7 (19.7–28.3)	223	38.7 (31.8–46.2)
Emergency care (yes)^d	550	19.3 (16.8–22.1)	1,004	26.1 (22.9–29.6)	236	39.4 (34.0–45.2)	< 0.001
Hospitalization (yes)^d	203	7.9 (6.5–9.5)	383	10.8 (8.8–13.2)	113	19.9 (15.4–25.3)	< 0.001

Medicines	ATC Code (5^th level)^b	n^c	% (95%CI)
Simvastatin	C10AA01	224	35.7 (29.9–42.0)
Losartan	C09CA01	213	34.0 (26.9–41.8)
Omeprazole	A02BC01	200	33.6 (28.3–39.4)
Acetylsalicylic acid	N02BA01	175	26.5 (20.3–33.7)
Metformin	A10BA02	161	24.8 (18.1–33.0)
Hydrochlorothiazide	C03AA03	159	23.5 (16.8–31.9)
Enalapril	C09AA02	101	15.8 (10.9–22.3)
Atenolol	C07AB03	101	15.0 (10.3–21.5)
Captopril+diuretic	C09BA01	65	12.2 (7.0–20.5)
Fluoxetine^d	N06AB03	64	12.2 (9.3–15.9)
Glibenclamide	A10BB01	67	11.4 (7.7–16.5)
Captopril	C09AA01	61	11.3 (8.0–15.7)
Clonazepam^d	N03AE01	60	11.2 (8.9–13.9)
Dipyrone	N02BB02	50	10.0 (6.5–15.2)
Ibuprofen^d	C01EB16	52	9.7 (7.1–13.2)
Propranolol	C07AA05	52	8.8 (6.2–12.5)
Paracetamol	N02BE01	58	8.7 (6.6–11.3)
Furosemide	C03CA01	55	8.7 (6.8–11.0)
Amlodipine	C08CA01	64	8.5 (5.6–12.8)
Losartan+diuretic	C09DA01	41	8.3 (4.0–16.3)
Diazepam^d	N05BA01	40	7.4 (3.9–13.6)
Diclofenac	M01AB05	30	6.8 (4.6–10.1)
Amitriptyline^d	N06AA09	48	6.6 (4.5–9.7)
Metformin+sulfonylurea	A10BD02	24	6.0 (2.0–17.1)
Atenolol+thiazides	C07BB03	33	5.3 (2.4–11.5)

Variable	Univariate		p	Multiple^a		p

	OR	95%CI		OR	95%CI
Intercept	–	–	–	0.004	0.002–0.008	< 0.001
Sex
Male	–	–	–
Female	1.266	0.954–1.680	0.103
Age (years)
18–44	–	–	–	–	–	–
45–64	5.279	3.499–7.964	< 0.001	1.946	1.275–2.970	< 0.001
≥ 65	7.316	4.904–10.914	< 0.001	2.428	1.541–3.825	< 0.001
Education level
Higher education	–	–	–
High school	1.131	0.603–2.121	0.702
Elementary or middle school	2.069	1.051–4.071	0.036
Some elementary or middle school	3.176	1.768–5.706	< 0.001
Illiterate	4.296	2.177–8.474	< 0.001
Marital status
Single	–	–	–
Married/common-law marriage	2.202	1.572–3.084	< 0.001
Others	4.119	2.804–6.049	< 0.001
Economic class
A or B	–	–	–
C	1.072	0.764–1.504	0.686
D or E	1.143	0.717–1.823	0.574
Has health insurance
No	–	–	–	–	–	–
Yes	2.004	1.582–2.538	< 0.001	1.602	1.125–2.278	0.009
Hypertension
No	–	–	–	–	–	–
Yes	6.633	4.765–9.234	< 0.001	3.496	2.345–5.211	< 0.001
Diabetes mellitus
No	–	–	–	–	–	–
Yes	4.177	3.226–5.408	< 0.001	2.297	1.753–3.009	< 0.001
Depression
No	–	–	–	–	–	–
Yes	3.725	3.002–4.623	< 0.001	2.381	1.862–3.044	< 0.001
Arthritis
No	–	–	–	–	–	–
Yes	4.052	3.179–5.163	< 0.001	1.736	1.314–2.295	< 0.001
Self-perception of health
Good/Very good	–	–	–	–	–	–
Neither good nor bad	2.871	2.289–3.602	< 0.001	1.823	1.400–2.375	< 0.001
Bad/Very bad	6.244	4.525–8.615	< 0.001	2.912	1.935–4.380	< 0.001
Country region
North	–	–	–	–	–	–
Midwest	2.820	1.359–5.851	0.005	2.304	1.096–4.844	0.027
Northeast	3.542	1.814–6.913	< 0.001	2.767	1.358–5.638	0.005
Southeast	3.648	1.894–7.024	< 0.001	2.621	1.266–5.430	0.010
South	8.829	4.867–16.015	< 0.001	5.815	3.133–10.794	< 0.001
Emergency care
No	–	–	–	–	–	–
Yes	2.144	1.688–2.722	< 0.001	1.592	1.198–2.114	< 0.001
Hospitalization
No	–	–	–	–	–	–
Yes	2.346	1.718–3.204	< 0.001

[TFN1] * non-weighted n-value.

[TFN2] Source: PNAUM- Services, 2015.

Polypharmacy: a challenge for the primary health care of the Brazilian Unified Health System

ABSTRACT