Polypharmacy and Complex Wounds

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Introduction

Patients with wounds are frequently treated pharmacologically for both their wounds and their acute or chronic conditions. On a daily basis, patients usually take at least 5 prescription medications to treat multiple chronic conditions, and this level of drug use is termed polypharmacy. Polypharmacy can also be defined as the intake of more medications than are medically necessary for a particular problem or the continuation of intake after the initial problem has been resolved.1,2

Medications can significantly impair wound healing, as well as provoke a wound or skin response such as dehiscence and even infection. A medication’s effect on the wound healing process may vary in accordance with its mechanism of action, dosage, and route of administration in relation to the specific phase of the wound healing process. The wound healing cascade involves numerous growth factors and cytokines, and each of these phases is susceptible to interruption by certain oral drugs.2

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Polypharmacy can be caused by a variety of risk factors. Patient-related factors include the existence of several subspecialist physicians managing diverse medical problems, the presence of persistent mental illnesses, and residence in a long-term care facility. Variables such as improperly updated medical records, automated refill services, and prescriptions meant to meet disease-specific quality standards all contribute to this problem at the system level.3

Deprescribing Medications

Deprescribing medications related to polypharmacy should be considered by physicians as a therapeutic intervention. When deprescribing, clinicians should consider patient and caregiver perspectives on therapy goals, including drug and chronic condition views, as well as prescription preferences and priorities, to accelerate disease management, avoid health deterioration, and relieve symptoms. Point-of-care tools can help physicians deprescribe medications and can also help patients realize the importance of reducing their drug burden to lessen the consequences of polypharmacy.3

Medications That Affect Wound Healing

Medications that have been reported to delay wound healing include anticoagulants, antimicrobials, various antibiotic classes, bevacizumab, aflibercept, antineoplastic agents, chemotherapeutics, immunosuppressants, and colchicine. Of note are common substances which also delay wound healing, such as sodium hypochlorite and nicotine. 4

Anti-inflammatory Agents

Both short-term use and long-term use of steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to have a negative impact on wound healing and tissue repair.1

Antibiotics

Antibiotics should be prescribed only when there is an active wound infection. Both culture and sensitivity testing should be used to guide antibiotic selection, in keeping with antimicrobial stewardship. Prolonged use of topical antibiotics is discouraged to avoid the development of resistant organisms, thereby harming the effectiveness of future antibiotic use.1

Anticoagulants and Antiplatelet Agents

In view of a lack of clinical evidence, it has been speculated that both warfarin and heparin may cause a delay in wound healing by inhibiting fibrin production.1

Advanced Wound Care Therapies

Given the major issue of chronic wounds, clinicians confront the public health crisis with solutions such as advanced wound care therapies. There are situations where specific advanced therapies may be advantageous in the healing process for various chronic wounds and for those patients who require medications that may make wound healing difficult. The path to healing for many wounds begins with wound bed cleansing. In fact, the efficacy of numerous advanced therapies is contingent on good wound bed preparation that promotes healing. The success of advanced therapies relies on preparing the wound bed by reducing bacterial burden and inflammation.5

Antimicrobial Advanced Wound Care Dressings

Numerous innovative wound care dressings have been created specifically for the treatment of chronic wounds. These dressings include silver, polyhexamethylene biguanide (PHMB), medical-grade honey, povidone-iodine, dialkylcarbamoyl chloride (DACC), and chlorhexidine gluconate as antibacterial agents. These dressings may help to control the amount of bioburden in the wound and decrease protease activity.5 Antimicrobial dressings are not a replacement for systemic antibiotic treatment when an infection is present, but they can help to reduce bioburden in the wound and prevent infection, and they can also help to decrease extraneous antibiotic use.

Cellular and/or Tissue-Based Product Therapies

Cellular and/or tissue-based products (CTPs) have made significant advancements over the last several decades, thereby increasing clinicians’ ability to restore wounds more effectively. Products can be characterized as follows: nonviable cells, tissue-based, animal; nonviable cells, tissue-based, human; viable human cells, cultured in vitro, animal substrate; viable human cells, cultured in vitro, synthetic substrate; and viable human cells, noncultured, intact tissue. CTP examples include6:

  • Acellular matrices derived from xenogeneic collagen or tissue
  • Allogeneic matrices derived from human tissue (fibroblasts or membrane)
  • Composite matrices derived from human keratinocytes, fibroblasts, and xenogeneic collagen
  • Human skin allografts derived from donated human skin

These products are used as scaffolding to aid in new skin growth, and they can help in achieving wound closure.

Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT) has been shown to be an effective treatment for a variety of wound types, including complex nonhealing wounds. NPWT applies subatmospheric pressure to the surface of a wound that is sealed with a film dressing and connected by a tube to a suction pump and drainage collection system. NPWT is gaining popularity as a method to reduce the number of dressing changes required. It is simple to apply at the bedside and has been shown to promote healing and improve patient outcomes.5 NPWT can be used to remove excess drainage from the wound, to promote granulation tissue growth, and potentially to seal the wound against infection.

Conclusion

Data indicate that certain medications significantly impair wound healing and even result in skin and wound damage. Clinicians should have practical knowledge of their patient’s medications and certain drug classes to be more aware of the risks associated with the use of these agents.

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References

  1. Beitz J. Pharmacologic impact (aka “breaking bad”) of medications on wound healing and wound development: a literature-based overview. Ostomy Wound Manage. 2017;63(3):18-35. Accessed February 7, 2022. https://www.hmpgloballearningnetwork.com/site/wmp/article/pharmacologic-...
  2. Levine JM. How oral medications affect wound healing. Nursing. 2018;48(3):34-40. doi:10.1097/01.NURSE.0000530402.51912.a8
  3. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. Am Fam Physician. 2019;100:32-38. Accessed February 7, 2022. https://www.aafp.org/afp/2019/0701/p32.html
  4. Armstrong D, Bauer K, Bohn G, Carter M, Snyder R, Serena T. Principles of best diagnostic practice in tissue repair and wound healing; an expert consensus. Diagnostics (Basel). 2020;11(1):50. doi:10.3390/diagnostics11010050
  5. Chamanga ET. Clinical management of non-healing wounds. Nurs Stand. 2018;32(29):48-63. doi:10.7748/ns.2018.e10829
  6. Abdo J, Ortman H. Biologic and synthetic cellular and/or tissue-based products and smart wound dressings/coverings. Surg Clin North Am. 2020;100(4):741-756. doi:10.1016/j.suc.2020.05.006

Suggested Reading

Hassan El-Sabbagh AH. Negative pressure wound therapy: an update. Chin J Traumatol. 2017;20(2):103-107. doi:10.1016/j.cjtee.2016.09.004

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

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