[RATIONAL DE-PRESCRIBING TO TREAT POLYPHARMACY - COUNTERING THE FIRST IATROGENIC EPIDEMIC]

Improved medical technology is associated with rapidly growing sub-populations suffering from incurable co-morbidities for prolonged periods of time before death. Although there is no evidence based medicine (EBM) proving positive benefit/risk ratios for most medications in these sub-populations, it is evident that they are attended by an increased number of specialists, each of whom add medications based on "their" guidelines. Eventually, more people suffer from inappropriate medication use and polypharmacy (IMUP); IMUP's negative medical, economic and social consequences represent the 21st-century iatrogenic pandemic. Many barriers interfere with attempts to de-prescribe: The myth "drugs=health" is a deep-rooted value; de-prescribing is automatically perceived negatively; physicians are not trained to de-prescribe; and discussing de-prescribing with the patient/family is time consuming. In an era of defensive medicine, physicians have fears of lawsuits, of patient/family's reactions, fears of not following all guideline recommendations, despite the age-related decrease in their benefit/risk ratio. Like other pandemics, combined international efforts are required in order to manage IMUP effectively. The International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP) was established and has begun sowing the seeds of global collaboration. Partnership with patients/families in decision-making is essential in geriatric-palliative ethical approaches, to overcome barriers to de-prescribing. Borrowing the language of epidemics, several approaches of "curing the infected" (reducing polypharmacy) were suggested; Israeli studies have proven improved functional, mental and cognitive status and patient/family satisfaction, following massive de-prescribing, compared with those who adhered to standard recommendations. "Immunization" (prevention), should concentrate on early education of professionals and laymen about IMUP and de-prescribing. Rational de-prescribing represents "a triple-win-win game"- improves life quality in the last years of life and has huge economic benefits.