Walk into any general medicine or geriatric OPD in India and you will encounter what clinicians now call the ‘prescription cascade’ — a patient on 8, 10, sometimes 14 different medications, many prescribed by different specialists who never saw the complete medication list. Polypharmacy, defined as concurrent use of 5 or more medications, affects an estimated 40% of elderly patients in urban Indian OPDs. The consequences range from avoidable adverse drug reactions and hospitalisation to drug-induced falls, cognitive impairment, and death. Why Polypharmacy Is Worse in India Than in Western Countries India’s fragmented healthcare system is a polypharmacy factory. Patients routinely see a cardiologist, a diabetologist, a pulmonologist, and a GP — none of whom have access to the others’ prescriptions. Over-the-counter availability of many potent drugs (antacids, NSAIDs, antihistamines, steroids) compounds the problem. Additionally, a significant proportion of Indian patients combine allopathic drugs with Ayurvedic or herbal preparations, creating pharmacokinetic interactions that are rarely screened for. Ashwagandha with thyroid medications, gurmar with antidiabetics, and triphala with anticoagulants are among the combinations seen in clinical practice with real adverse consequences. The 10 Most Dangerous Drug Combinations in Indian OPDs 1. Warfarin + Aspirin: Major bleeding risk, seen commonly in post-AF patients who are also on antiplatelet therapy after a stent. 2. ACE inhibitor + ARB + diuretic (Triple whammy): Causes acute kidney injury, still prescribed in India. 3. Metformin + contrast: AKI risk; withhold metformin 48 hours before and after contrast procedures. 4. Fluoroquinolone + oral hypoglycaemics: Unpredictable hypoglycaemia or hyperglycaemia. 5. Statins + clarithromycin or azithromycin: Increased risk of myopathy and rhabdomyolysis. 6. SSRIs + NSAIDs: Significantly increased GI bleeding risk, a combination very common in elderly patients with depression and arthritis. 7. Digoxin + amiodarone: Digoxin toxicity from raised levels. 8. Lithium + NSAIDs: Lithium toxicity from reduced renal clearance. 9. Ciprofloxacin + antacids: Chelation reduces ciprofloxacin absorption by up to 90% — a prescription error seen daily. 10. Phenytoin + warfarin: Unpredictable INR fluctuations in both directions. The Prescription Cascade: Recognising and Stopping It The prescription cascade occurs when a side effect of one drug is misidentified as a new disease and treated with another drug. Classic Indian examples: a patient on amlodipine develops ankle oedema → prescribed a diuretic → develops hypokalemia → prescribed potassium supplements → develops dyspepsia → prescribed a PPI → develops hypomagnesemia. The solution is to always ask: ‘Could this new symptom be caused by a drug?’ before writing a new prescription. Tools like the START/STOPP criteria and the Beers criteria (adapted for Indian populations) are essential references for structured medication review. How to Do a Structured Medication Review in a Busy OPD A full medication reconciliation does not need to take 20 minutes. A structured 5-step review takes under 5 minutes once habituated: 1) List every drug including OTCs and herbals. 2) For each drug ask: Is there still an indication? 3) Is the dose appropriate for the patient’s current renal and hepatic function? 4) Is there a drug-drug or drug-disease interaction? 5) Can anything be stopped (deprescribed)? Deprescribing is not failure — it is evidence-based practice. PPIs, benzodiazepines, and supplements are the most commonly overprescribed drug classes in India that can often be safely stopped or tapered. Q&A: What Doctors Are Searching About Polypharmacy Q: What is the safest way to stop a PPI a patient has been on for years? A: Taper gradually rather than stopping abruptly to avoid rebound acid hypersecretion. Halve the dose for 2–4 weeks, then switch to on-demand dosing. Warn the patient they may experience temporary heartburn. Long-term PPI use is associated with hypomagnesemia, C. difficile infection, and fracture risk — the risk-benefit needs revisiting at every annual review. Q: Is it safe to prescribe NSAIDs to a patient on antihypertensives? A: NSAIDs blunt the effect of most antihypertensive classes especially ACE inhibitors, ARBs, and diuretics, and can raise BP by 3–5 mmHg on average. In patients with CKD, heart failure, or established cardiovascular disease, NSAIDs are contraindicated. For pain in these patients, paracetamol (at lowest effective dose) is preferred. If an NSAID is unavoidable in a lower-risk patient, use the lowest dose for the shortest duration with a PPI cover. Q: How do I explain deprescribing to a patient who insists on their medications? A: Framing matters enormously. Do not say ‘I am stopping your tablet.’ Say: ‘Your body has changed and this medicine may now be doing more harm than good. We are going to make your treatment safer and simpler.’ Patients who understand the why are far more receptive. Shared decision-making is not just an ethical imperative — it improves adherence to whatever regimen remains. Q: What free tools can I use to check drug interactions quickly during an OPD? A: Medscape Drug Interaction Checker, Drugs.com interaction tool, and the Micromedex database (available via many hospital library subscriptions) are the most reliable. For a quick mobile reference, the CIMS India app and the Epocrates app are widely used by Indian doctors. Always cross-check when prescribing 5 or more drugs to any patient. How Doctrust Helps You Manage Polypharmacy Safely Doctrust’s smart prescription platform is built for the complexity of the Indian OPD. Our digital prescription tool flags known drug interactions at the point of prescribing, maintains a complete medication history across visits, and supports structured medication review workflows — so you can protect your patients from polypharmacy harm without slowing down your clinic. See how it works at www.doctrust.in