60 ORIGINAL ARTICLE Acta Med Indones - Indones J Intern Med • Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients Visiting Emergency Unit Czeresna H. Soejono, Aulia Rizka Division of Geriatric, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Corresponding author: Czeresna Heriawan Soejono, MD., PhD. Division of Geriatric, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta 10430, Indonesia. email: ch.soejono@gmail.com. AbstrAk Latar belakang: polifarmasi merupakan masalah kesehatan besar bagi pasien usia lanjut terkait dengan risiko morbiditas karena interaksi obat dan efek simpang obat. Profil polifarmasi di Unit Gawat Darurat pada pasien usia lanjut belum banyak diketahui. Penelitian ini bertujuan mengetahui prevalensi polifarmasi di IGD dan faktor yang memengaruhinya. Metode: studi potong lintang antara Juli hingga Desember 2018 pada UGD RS Cipto Mangunkusumo Jakarta Indonesia, melibatkan seluruh pasien berusia lanjut. Dilakukan evaluasi pola penggunaan obat menggunakan sistem ATC dan dicari hubungan antara polifarmasi dengan jenis kelamin, usia dan jumlah komorbid. Hasil: 475 pasien usia lanjut mengunjungi UGD (54,8% laki-laki dengan rerata usia 67.69 (SD 6.58) tahun. Polifarmasi didapatkan pada 57.6% subyek. Obat yang paling banyak digunakan adalah obat untuk saluran cerna dan gangguan metabolisme, diikuti dengan suplementasi darah, obat kardiovaskular dan antibiotika. Jumlah komorbid berhubungan dengan polifarmasi namun tidak dengan jenis kelamin dan usia. Kesimpulan: polifarmasi pada usia lanjut banyak ditemukan dan membutuhkan perhatian khusus dari klinisi. Kata kunci: polifarmasi, geriatri, unit kegawatdaruratan, obat. AbstrAct Background: polypharmacy is a major concern for elderly patients, as it links to high morbidity related to drug interaction and adverse drug effects. Not much is known about profile of polypharmacy among elderly subjects visiting emergency department (ED) for acute conditions. Methods: a cross sectional study conducted between July to December 2018 in ED of Cipto Mangunkusumo Hospital Jakarta Indonesia. All elderly patients admitted to ED were included. We evaluated drug use pattern using ATC system along with the association between polypharmacy with sex, age and number of comorbidities. Results: 475 geriatric patients visited EU 247 subjects were male (54.8%; mean age 67.69 (SD 6.58) years old). Polypharmacy was found in 57.6% subjects. The most frequently used of drug was that of alimentary tract and metabolism pharmacologic group, followed by drugs related to blood and blood forming organs, cardiovascular system, and anti-infectives for systemic use. Sex and age were not associated with polypharmacy, while more than 3 comorbidities was associated with polypharmacy. Conclusion: polypharmacy is prevalent among elderly visiting ED in Indonesia, requiring special attention from clinician to evaluate each drug and interaction among the drugs used. Keywords: polypharmacy, geriatric, emergency unit, drug. Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients IntroDUctIon The number of elderly people in Indonesia will reach 28.283.200 in 2030 (9,6% of total population). Strident increase will be seen in 2045 whereas it will comprise 19.7% of total population or 43,370,400 people.1 Disease accumulation in this particular group will put them in the risk of polypharmacy. Polypharmacy due to multiple pathology is of great importance as it has something to do with supply chain management especially in regards to the huge amount of drugs procurement; which in turn affects financial aspect.2,3 Drug pattern usage data of geriatric patients with polypharmacy are very scarce in Indonesia; not to mention its risk factors that play important role. It is very crucial to have this data in health facility. It will help managing medication availability and at the same time evaluate drug usage for better planning and quality of care. Polypharmacy also increases the risk of adverse event and occurrence of drug interactions. Ageing itself plays an important role in the development of side effects due to drug accumulation. Lipophilic substance will have broader volume distribution as the increase of body fat in elderly. Hydrophilic agents with higher protein affinity will have higher free concentration in the plasma as hypoalbuminemia is frequent among geriatric patients. Decrease drug metabolism with reduction in glomerular filtration will increase drug toxicity due to accumulation.4 Emergency Department (ED) is a starting point of drug usage for some patients including geriatric patients. Drug reconciliation process often missed as patients come in acute condition that required more attention; thus geriatric patients have a greater risk of polypharmacy. Over or under prescription leading to iatrogenic diseases might frequently occur in ED where time limitation is a major concern for the clinicians. Not much is known about the drug pattern used by geriatric patients visiting EU and factors related with the polypharmacy. Aim of this research was to identify drug pattern in geriatric patients admitted in EU with polypharmacy along with related factors that might contribute to its occurrence. MEthoDs A cross sectional study was conducted from July – December 2018) at Emergency Department (ED) of Cipto Mangunkusumo Hospital (RSCM) Jakarta, a national referral hospital in Indonesia. Study population were all elderly patients consecutively admitted to ED, due to acute or acute on chronic condition.5 Measurement and Data collection Presenting symptoms, major diagnosis, comorbidities, patients’ medications (active substance), sex, and age were recorded. Active substances were classified using anatomical therapeutic chemical (ATC) system. All information were collected from the patients’ medical records. Two independent physicians reviews the drugs used by the patients for the purpose of the study. Age was grouped in two: 60 – 69 years and > 70 years.6 Presenting symptoms, major diagnosis, and comorbidities were reported as absolute number as well as percentage. One major diagnosis might be accompanied by more than one comorbidities. According to ATC system, the most commonly used medications were then categorized towards three classifications: low (prescribed < 10%), moderate (between 10 – 40%), and high (> 40%). We define polypharmacy as using 5 or more drugs. statistical Analysis Data were analyzed using statistical package for social sciences (SPSS), version 24.0. Spearman test was used to see the correlation between age and number of drugs, as well as age and number of diagnosis (comorbidities) if the data were normally distributed.. For the same reason, Mann-Whitney test was used to analyze the correlation between categorical data and number of drugs. Ethical Approval This study was part of epidemiological study of elderly patients visiting ED of Cipto Mangunkusumo Hospital. This study was approved by Faculty of Medicine University of Indonesia Medical Ethics Committee (0859/ UN2.F1/ETIK/2018). 61 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med rEsUlts During July – December 2018 there were 475 elderly patients visited EU RSCM; 24 patients did not receive any medications; resulting 451 patients receiving active substances (Table 1). Two hundred and four were female (45.2%; mean age 69.17 (SD 8.01) years old); 247 subjects were male (54.8%; mean age 67.69 (SD 6.58) years old). Number of age group 60-69 years, >70 years, were 287 subjects and 164 subjects, respectively. From 451 subjects, 2494 active substances were identified; whereby 1,639 medications, and 855 medications, were identified being given to those in age group of 60-69 years, and >70 years, respectively. Two hundred and sixty subjects (57.6%) were recorded as having polypharmacy. Presenting symptoms of respiratory, gastrointestinal, neurological system, pain, and fatigue predominate the chief complaint, as seen in Table 2. Malignancies, infection, cardiovascular diseases, digestive diseases, and metabolic encephalopathy were the top five main diagnosis with variety of comorbidities especially anemia, hypertension, arthritis, renal disease, and T2DM (type 2 diabetes mellitus). The most frequent substance being used were sodium chloride solution, followed by paracetamol, ranitidine, ceftriaxone, and omeprazole. Besides ranitidine and omeprazole, propulsive and sucralfate were also quite frequent being prescribed for gastrointestinal problem. Ceftriaxone and levofloxacine were the most frequent anti-infective agent being used for combating infection. (Table 3) Most frequent medications were quite the same between two age groups (60 – 69 years and > 70 years) as seen in Table 4. The highest number was alimentary tract and metabolism table 2. Primary Complaint, Main Diagnosis, and most frequent Comorbidity in Emergency Unit. characteristic (n = 451) n (%) Primary Complaint Respiratory system Gastrointestinal system Neurology Pain Fatigue Trauma Cardiology Skin and musculoskeletal Reproduction and urinary system Fever Bleeding 91 (20.2) 66 (14.6) 66 (14.6) 61 (13.5) 51 (11.4) 31 (6.9) 26 (5.8) 16 (3.5) 15 (3.3) 15 (3.3) 13 (2.9) Main Diagnosis Malignancy Infection Hemodynamic, cardiac disease, vascular Digestive disease Metabolic encephalopathy Neurologic disease Skin and musculoskeletal disease Hematologic disease Urinary tract disease Respiratory disease 106 (23.5) 70 (15.5) 67 (14.8) 51 (11.4) 49 (10.8) 37 (8.3) 24 (5.3) 18 (3.9) 17 (3.8) 12 (2.7) Comorbidity* Anemia Hipertention Arthritis Renal disease T2DM Electrolyte imbalance Hypoalbuminemia Cancer Pneumonia Stroke 309 (65.6) 301 (63.9) 241 (51.2) 214 (45.5) 185 (39.3) 176 (37.4) 138 (29.3) 137 (29.1) 125 (26.5) 93 (19.8) *One main diagnosis could have several comorbidities table 3. Top Active Substances Prescribed to Study Participants. no name Atc code Frequency Percentage 1 NaCl B05CB 255 10.22 2 Paracetamol N02BE 150 6.01 3 Ranitidine A02BA 148 5.93 4 Ceftriaxone J01DD 142 5.69 5 Omeprazole A02BC 96 3.85 6 NAC R05CB 86 3.65 7 Propulsives A03FA 75 3.01 8 Amlodipine C08CA 70 2.81 9 HMG CoA red inh C10AA 59 2.37 10 ACE inh C09AA 56 2.25 11 Levofloxacine J01MA 50 2.00 12 Sucralfate A02BX 49 1.96 13 Corticosteroids S02BA 31 1.24 14 Mefenamic acid M01AG 22 0.88 15 Diet form V06DC 19 0.76 Name of substances: in any concentration or dosage ATC code: anatomical therapeutic chemical code NAC: N-acetyl cysteine HMG CoA red inh: hydroxymethylglutaryl-coenzyme A reductase inhibitor ACE inh: angiotensin-converting enzyme inhibitor Diet form: diet formulation for therapy of obesity (carbohydrates) table 1. Characteristics of subjects (n = 451). characteristics n (%) Sex Male Female 247 (54.8) 204 (45.2) Age 60-69 years old > 70 years old 287 (63.6) 164 (36.4) Polypharmacy Yes (number of drugs > 5) No (number of drugs < 5) 260 (57.6) 191 (42.4) 62 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients table 4. Distribution of Active Substances According to Pharmacologic Group in Study Participants Conferring to Age Group. Pharmacologic group 60-69 Years >=70 Years total Male n = 164 Female n = 123 Male n = 83 Female n = 81 Male n = 247 Female n = 204 overall n = 451 A = Alimentary tract and metabolism 227 181 95 113 322 294 616 B = Blood and blood forming organs 193 138 80 108 273 246 519 C = Cardiovascular system 172 99 66 65 238 164 402 D = Dermatologicals 4 9 4 0 8 9 17 G = Genito urinary system and sex hormones 4 4 3 2 7 6 13 H = Systemic hormonal preparations, excl. sex hormones and insulins 3 10 4 0 7 10 17 J = Anti-infectives for systemic use 140 96 60 84 200 180 380 L = Antineoplastic and immunomodulating agents 1 3 0 0 1 3 4 M = Musculo-skeletal system 20 14 6 14 26 28 54 N = Nervous system 90 66 47 23 137 89 226 R = Respiratory system 61 42 27 31 88 73 161 S = Sensory organs 32 10 10 2 42 12 54 V = Various 12 8 5 6 17 14 31 table 5. Association Between Number of Drug Used and Sex. Men (n=247) Women (n=204) p-value Number of drugs (median [min-max]) 5 (1-14) 5 (1-14) 0.885* *Mann-Whitney test (non-parametric test was used as data distribution was not normal). pharmacologic group, followed by blood and blood forming organs, cardiovascular system, and antiinfectives for systemic use. There was no correlation between age group and number of drugs being used (r=-0.076, p=0.107). There was neither any association between sex and number of drugs used (Table 5). Significant association were neither seen between sex or age group with the existance of polypharmacy (Table 6). The mode as well as the median number of chronic diseases were three. Higher proportion of polypharmacy was seen in patients with more than three chronic diseases, whereas patient with three or less chronic diseases was more likely to have no polypharmacy (p 0.000; OR 2.554 [1.724 – 3.783]). There was neither seen any correlation between age group and number of chronic diseases (r=-0.056, p=0.237). The complete pattern of drugs used according ATC grouping were seen in Table 7. The result will be described further according to the frequency of their usage. Firstly, from Alimentary and Metabolism (616 prescriptions [20.89%]), H2 receptor antagonist ranitidine was the most frequent medication prescribed (148 or 5.93%); followed by proton pump inhibitor (96 or 3.85%), propulsive (75 or 3.01%), and insulin (46 or 1.84%). Secondly, from Blood and Blood Forming Organs (519 prescriptions [20.81%]), normal saline was the most frequent substance prescribed (255 or 10.22%); followed by platelet aggregation inhibitor (120 or 4.81%), amino-acids solutions (39 or 1.56%), and heparin group (28 or 1.12%). Thirdly, from Cardiovascular System (402 prescriptions [16.12%]), dihydropyridine derivatives (selective calcium channel blocker) was the most frequent medication prescribed (70 or 2.81%); followed by lipid modifying agents i.e. HMG CoA reductase inhibitors (59 or 2.37%), ACE inhibitors (56 or 2.25%), beta 63 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med table 6. Association Between Sex, Age Group, and Number of Chronic Diseases and Number of Drugs Used. Polypharmacy (n=260) not Polypharmacy (n=191) p-Value or (95% cI) Sex - Male - Female 146 (56.2) 114 (43.8) 101 (52.9) 90 (47.1) 0.490 1.141 (0.784-1.661) Age - > 70 - 60-69 90 (34.6) 170 (65.4) 74 (38.7) 117 (61.3) 0.368 0.837 (0.568 – 1.233) Number of chronic diseases - > 3 - < 3 137 (52.7) 123 (47.3) 58 (30.4) 133 (69.6) 0.000 2.554 (1.724 – 3.783) blocking agents (55 or 2.21%), and sulfonamide diuretic (51 or 2.04%). Fourthly, from the Anti-infectives for Systemic Use (380 prescriptions [15.24%]), third generation cephalosporins was the most frequent medications prescribed (142 or 5.69%), followed by fluoroquinolones (50 or 2.00%), macrolides (40 or 1. 64%), other beta-lactam antibacterials (36 or 1.44%), and extended spectrum penicillins (28 or 1.12%). The fifth, from the Nervous System (226 prescription [9.06%]), analgesic antipyretics anilides was the most frequent substance prescribed (150 or 6.01%), followed by opioids phenylpiperidine derivatives (12 or 0.48%), opioid alkaloids (11 or 0.44%), and benzodiazepine derivatives (10 or 0.40%). Number six, from the Respiratory System (161 prescription [6.46%]), mucolytics (N-acetyl cysteine) was the most frequent substance prescribed (86 or 3.65%). DIscUssIon In this study population, the percentage of male (54.8%) and female (45.2%) subjects were equally distributed. Al Ameri (2014) and Tan (2019) reported the same gender percentage of polypharmacy.5,7 In Indonesian general population, elderly female population is higher than the male.8 The difference in this observation was probably due to the fact that the study population was derived from elderly with acute illnesses that should be treated in an emergency setting whereby the possibility of having such an emergency clinical presentation was similar between these two gender groups.9 The percentage of those age group of 60 – 69 years was higher than age group > 70 years; this observation was different from those who were admitted for inpatient whereby the older old (> 70 years) was higher than the younger ones.8 Those who were more severely ill will be hospitalized while those lesser sick who were usually younger will be discharged from ED and visit the outpatient clinic the next days of follow up.9 The prevalence of polypharmacy was 57.6% with the most frequent active substances were: normal saline, ranitidine, paracetamol, ceftriaxone, and omeprazole. Those active substances were concordance with the most frequent diagnosis (malignancy, infection, hemodynamic disturbances, digestive system) and/ or primary complaints (respiratory symptoms, gastrointestinal, neurology, and pain) of the subjects. This observation was quite the same as observed by Santalucia et al (2015) whereby the usage of alimentary tract and metabolism class, blood and blood forming organs system , cardiovascular system, and nervous system pharmacological class were predominant.10 Tan (2019) reported a lower percentage of polypharmacy (14.5%) among community-dwelling elderly, while Gupta (2018) and Al Ameri (2014) reported higher prevalence of polypharmacy of geriatric patients in hospital setting i.e 60.9% and 89.0% respectively.5,9 Elderly patients in the community represents those with less severe cases with less co-morbidity, while those in hospitals were 64 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients ta bl e 7. D ru g U til iz at io n P at te rn (A lim en ta ry T ra ct a nd M et ab ol is m ) D ru g U til iz at io n pa tte rn (% ) le ve l 1 n % le ve l 2 n % le ve l 3 n % le ve l 4 n % A = A lim en ta ry tra ct a nd m et ab ol is m 61 6 20 .8 9% A 01 :S to m at ol og ic al pr ep ar at io ns 3 0. 12 % A 01 A :S to m at ol og ic al pr ep ar at io ns 3 0. 12 % A 01 A B :C ar ie s pr op hy la ct ic ag en ts 3 0. 12 % A 02 :D ru gs fo r a ci d re la te d di so rd er s 29 3 11 .7 5% A 02 B :D ru gs fo r p ep tic ul ce r a nd g as tro - oe so ph ag ea l r efl ux di se as e (G E R D ) 29 3 11 .7 5% A 02 B A :H 2- re ce pt or an ta go ni st s 14 8 5. 93 % A 03 :D ru gs fo r f un ct io na l ga st ro in te st in al d is or de rs 79 3. 17 % A 03 B :B el la do nn a an d de riv at iv es , p la in 4 0. 16 % A 02 B C :P ro to n pu m p in hi bi to rs 96 3. 85 % A 04 :A nt ie m et ic s an d an tin au se an ts 2 0. 08 % A 03 F: P ro pu ls iv es 75 3. 01 % A 02 B X :O th er d ru gs fo r p ep tic ul ce r a nd g as tro -o es op ha ge al re flu x di se as e (G E R D ) 49 1. 96 % A 05 :B ile a nd li ve r t he ra py 2 0. 08 % A 04 A :A nt ie m et ic s an d an tin au se an ts 2 0. 08 % A 03 B A :B el la do nn a al ka lo id s, te rti ar y am in es 3 0. 12 % A 06 D ru gs fo r c on st ip at io n 54 2. 17 % A 05 A :B ile th er ap y 2 0. 08 % A 03 B B :B el la do nn a al ka lo id s, se m is yn th et ic , q ua te rn ar y am m on iu m c om po un ds 1 0. 04 % A 07 :A nt id ia rr he al s, in te st in al an tii nfl am at or y/ an tii nf ec tiv e ag en ts 10 0. 40 % A 06 A :D ru gs fo r co ns tip at io n 54 2. 17 % A 03 FA :P ro pu ls iv es 75 3. 01 % A 10 :D ru gs u se d in d ia be te s 80 3. 21 % A 07 A :In te st in al an tii nf ec tiv es 2 0. 08 % A 04 A A :S er ot on in (5 H T3 ) an ta go ni st s 2 0. 08 % A 11 :V ita m in s 15 0. 60 % A 07 B :In te st in al a ds or be nt s 5 0. 20 % A 05 A A :B ile a ci ds a nd de riv at iv es 2 0. 08 % A 12 :M in er al s up pl em en ts 79 3. 17 % A 07 D :A nt ip ro pu ls iv es 2 0. 08 % A 06 A B :C on ta ct la xa tiv es 29 1. 16 % A 07 E :In te st in al an tii nfl am m at or y ag en ts 1 0. 04 % A 06 A D :O sm ot ic al ly a ct in g la xa tiv es 25 1. 00 % A 10 A :In su lin s an d an al og ue s 64 2. 57 % A 07 A A :A nt ib io tic s 2 0. 08 % 65 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med A 10 B :B lo od g lu co se lo w er in g dr ug s, e xc l. in su lin s 16 0. 64 % A 07 B C :O th er in te st in al ad so rb en ts 5 0. 20 % A 11 C :V ita m in A a nd D , i nc l. co m bi na tio ns o f t he tw o 1 0. 04 % A 07 D A :A nt ip ro pu ls iv es 2 0. 08 % A 11 D :V ita m in B 1, p la in a nd in c om bi na tio n w ith v ita m in B 6 an d B 12 1 0. 04 % A 07 E C :A m in os al ic yl ic a ci d an d si m ila r a ge nt s 1 0. 04 % A 11 E :V ita m in B -c om pl ex , in cl . c om bi na tio ns 3 0. 12 % A 10 A B :In su lin s an d an al og ue s fo r i nj ec tio n, fa st -a ct in g 46 1. 84 % A 11 G :A sc or bi c ac id (v ita m in C ), in cl . co m bi na tio ns 3 0. 12 % A 10 A D :In su lin s an d an al og ue s fo r i nj ec tio n, in te rm ed ia te - o r lo ng -a ct in g co m bi ne d w ith fa st -a ct in g 5 0. 20 % A 11 H :O th er p la in v ita m in pr ep ar at io ns 7 0. 28 % A 10 A E :In su lin s an d an al og ue s fo r i nj ec tio n, lo ng -a ct in g 13 0. 52 % A 12 A :C al ci um 34 1. 36 % A 10 B A :B ig ua ni de s 7 0. 28 % A 12 B :P ot as si um 31 1. 24 % A 10 B B :B ig ua ni de s 9 0. 36 % A 12 C :O th er m in er al su pp le m en ts 14 0. 56 % A 11 C C :V ita m in D a nd an al og ue s 1 0. 04 % A 11 D A :V ita m in B 1, p la in 1 0. 04 % A 11 E A :V ita m in B -c om pl ex , pl ai n 3 0. 12 % A 11 G A :A sc or bi c ac id (v ita m in C ), pl ai n 3 0. 12 % A 11 H A :O th er p la in v ita m in pr ep ar at io ns 7 0. 28 % A 12 A A :C al ci um 34 1. 36 % A 12 B A :P ot as si um 31 1. 24 % A 12 C A :S od iu m 11 0. 44 % A 12 C B :Z in c 1 0. 04 % A 12 C C :M ag ne si um 2 0. 08 % 66 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients B = B lo od a nd bl oo d fo rm in g or ga ns 51 9 20 .8 1% B 01 :A nt ith ro m bo tic a ge nt s 15 0 B 01 A :A nt ith ro m bo tic ag en ts 15 0 6. 01 % B 01 A A :V ita m in K a nt ag on is ts 1 0. 04 % B 02 :A nt ih em or rh ag ic s 56 B 02 A :A nt ifi br in ol yt ic s 39 1. 56 % B 01 A B :H ep ar in g ro up 28 1. 12 % B 03 :A nt ia ne m ic p re pa ra tio ns 12 B 02 B :V ita m in K a nd o th er he m os ta tic s 17 0. 68 % B 01 A C :P la te le t a gg re ga tio n in hi bi to rs e xc l. he pa rin 12 0 4. 81 % B 05 :B lo od s ub st itu te s an d pe rfu si on s ol ut io ns 30 1 B 03 B :V ita m in B 12 a nd fo lic a ci d 12 0. 48 % B 01 A D :E nz ym es 1 0. 04 % B 05 A :B lo od a nd re la te d pr od uc ts 18 0. 72 % B 02 A A :A m in o ac id s 39 1. 56 % B 05 B :I. v. s ol ut io ns 16 0. 64 % B 02 B A :V ita m in K 17 0. 68 % B 05 C :Ir rig at in g so lu tio ns 26 3 10 .5 5% B 03 B A :V ita m in B 12 (c ya no co ba la m in a nd an al og ue s) 5 0. 20 % B 05 X :I. v. s ol ut io n ad di tiv es 4 0. 16 % B 03 B B :F ol ic a ci d an d de riv at iv es 7 0. 28 % B 05 A A :B lo od s ub st itu te s an d pl as m a pr ot ei n fra ct io ns 12 0. 48 % B 05 A X :O th er b lo od p ro du ct s 6 0. 24 % B 05 B A :S ol ut io ns fo r p ar en te ra l nu tri tio n 2 0. 08 % B 05 B B :S ol ut io ns a ffe ct in g th e el ec tro ly te b al an ce 13 0. 52 % B 05 B C :S ol ut io ns p ro du ci ng os m ot ic d iu re si s 1 0. 04 % B 05 C B :S al t s ol ut io ns 25 5 10 .2 2% B 05 C X :O th er ir rig at in g so lu tio ns 8 0. 32 % B 05 X A :E le ct ro ly te s ol ut io ns 4 0. 16 % C = C ar di ov as cu la r sy st em 40 2 16 .1 2% C 01 :C ar di ac th er ap y 45 1. 80 % C 01 A :C ar di ac g ly co si de s 8 0. 32 % C 01 A A :D ig ita lis g ly co si de s 8 0. 32 % C 02 :A nt ih yp er te ns iv es 12 0. 48 % C 01 C :C ar di ac s tim ul an ts ex cl . c ar di ac g ly co si de s 12 0. 48 % C 01 C A :A dr en er gi c an d do pa m in er gi c ag en ts 12 0. 48 % 67 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med C 03 :D iu re tic s 57 2. 29 % C 01 D :V as od ila to rs u se d in ca rd ia c di se as es 24 0. 96 % C 01 D A :O rg an ic n itr at es 24 0. 96 % C 07 :B et a bl oc ki ng a ge nt s 61 2. 45 % C 01 E :O th er c ar di ac pr ep ar at io ns 1 0. 04 % C 01 E B :O th er c ar di ac pr ep ar at io ns 1 0. 04 % C 08 :C al ci um c ha nn el bl oc ke rs 70 2. 81 % C 02 A :A nt ia dr en er gi c ag en ts , c en tra lly a ct in g 12 0. 48 % C 02 A C :Im id az ol in e re ce pt or ag on is ts 12 0. 48 % C 09 :A ge nt s ac tin g on th e re ni n- an gi ot en si n sy st em 97 3. 89 % C 03 A :L ow -c ei lin g di ur et ic s, th ia zi de s 2 0. 08 % C 03 A A :T hi az id es , p la in 2 0. 08 % C 10 :L ip id m od ify in g ag en ts 60 2. 41 % C 03 C :H ig h- ce ili ng d iu re tic s 51 2. 04 % C 03 C A :S ul fo na m id es , p la in 51 2. 04 % C 03 D :P ot as si um -s pa rin g ag en ts 4 0. 16 % C 03 D A :A ld os te ro ne an ta go ni st s 4 0. 16 % C 07 A :B et a bl oc ki ng a ge nt s 61 2. 45 % C 07 A A :B et a bl oc ki ng a ge nt s, no n- se le ct iv e 2 0. 08 % C 08 C :S el ec tiv e ca lc iu m ch an ne l b lo ck er s w ith m ai nl y va sc ul ar e ffe ct s 69 2. 77 % C 07 A B :B et a bl oc ki ng a ge nt s, se le ct iv e 55 2. 21 % C 08 D :S el ec tiv e ca lc iu m ch an ne l b lo ck er s w ith di re ct c ar di ac e ffe ct s 1 0. 04 % C 07 A G :A lp ha a nd b et a bl oc ki ng a ge nt s 4 0. 16 % C 09 A :A C E in hi bi to rs , p la in 56 2. 25 % C 08 C A :D ih yd ro py rid in e de riv at iv es 70 2. 81 % C 09 C :A ng io te ns in II re ce pt or b lo ck er s (A R B s) , pl ai n 41 1. 64 % C 08 D B :B en zo th ia ze pi ne de riv at iv es 1 0. 04 % C 10 A :L ip id m od ify in g ag en ts , p la in 60 2. 41 % C 09 A A :A C E in hi bi to rs , p la in 56 2. 25 % C 09 C A :A ng io te ns in II re ce pt or bl oc ke rs (A R B s) , p la in 41 1. 64 % C 10 A A :H M G C oA re du ct as e in hi bi to rs 59 2. 37 % 68 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients C 10 A B :F ib ra te s 1 0. 04 % D = D er m at ol og ic al s 17 0. 68 % D 02 :E m ol lie nt s an d pr ot ec tiv es 1 0. 04 % D 02 A :E m ol lie nt s an d pr ot ec tiv es 1 0. 04 % D 02 A X :O th er e m ol lie nt s an d pr ot ec tiv es 1 0. 04 % D 04 :A nt ip ru rit ic s, in cl , an tih is ta m in es , a ne st he tic s, et c. 13 0. 52 % D 04 A :A nt ip ru rit ic s, in cl . a nt ih is ta m in es , an es th et ic s, e tc . 13 0. 52 % D 04 A A :A nt ih is ta m in es fo r to pi ca l u se 13 0. 52 % D 06 :A nt ib io tic s an d ch em ot he ra pe ut ic s fo r de rm at ol og ic al u se 2 0. 08 % D 06 A :A nt ib io tic s fo r t op ic al us e 2 0. 08 % D 06 A X :O th er a nt ib io tic s fo r to pi ca l u se 2 0. 08 % D 07 :C or tic os te ro id s, de rm at ol og ic al p re pa ra tio ns 1 0. 04 % D 07 X :C or tic os te ro id s, ot he r c om bi na tio ns 1 0. 04 % D 07 X A :C or tic os te ro id s, w ea k, ot he r c om bi na tio ns 1 0. 04 % G = G en ito u rin ar y sy st em a nd s ex ho rm on es 13 0. 52 % G 01 :G yn ec ol og ic al an tii nf ec tiv es a nd a nt is ep tic s 10 0. 40 % G 01 A :A nt iin fe ct iv es an d an tis ep tic s, e xc l. co m bi na tio ns w ith co rti co st er oi ds 10 0. 40 % G 01 A F: Im id az ol e de riv at iv es 10 0. 40 % G 04 :U ro lo gi ca ls 3 0. 12 % G 04 B :U ro lo gi ca ls 1 0. 04 % G 04 B E :D ru gs u se d in e re ct ile dy sf un ct io n 1 0. 04 % G 04 C :D ru gs u se d in b en ig n pr os ta tic hy pe rtr op hy 2 0. 08 % G 04 C A :A lp ha -a dr en or ec ep to r an ta go ni st s 2 0. 08 % H = S ys te m ic ho rm on al pr ep ar at io ns , e xc l. se x ho rm on es a nd in su lin s 17 0. 68 % H 01 :P itu ita ry a nd hy po th al am ic h or m on es a nd an al og ue s 3 0. 12 % H 01 C :H yp ot ha la m ic ho rm on es 3 0. 12 % H 01 C B :S om at os ta tin a nd an al og ue s 3 0. 12 % H 02 :C or tic os te ro id s fo r sy st em ic u se 10 0. 40 % H 02 A :C or tic os te ro id s fo r sy st em ic u se , p la in 10 0. 40 % H 02 A B :G lu co co rti co id s 10 0. 40 % H 03 :T hy ro id th er ap y 4 0. 16 % H 03 A :T hy ro id p re pa ra tio ns 2 0. 08 % H 03 A A :T hy ro id h or m on es 2 0. 08 % H 03 B :A nt ith yr oi d pr ep ar at io ns 2 0. 08 % H 03 B A :T hi ou ra ci ls 2 0. 08 % J = A nt iin fe ct iv es fo r s ys te m ic u se 38 0 15 .2 4% J0 1: A nt ib ac te ria ls fo r sy st em ic u se 34 4 13 .7 9% J0 1B :A m ph en ic ol s 5 0. 20 % J0 1B A :A m ph en ic ol s 5 0. 20 % J0 2: A nt im yc ot ic s fo r sy st em ic u se 2 0. 08 % J0 1C :B et a- la ct am an tib ac te ria ls , p en ic ill in s 44 1. 76 % J0 1C A :P en ic ill in s w ith ex te nd ed s pe ct ru m 28 1. 12 % 69 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med J0 4: A nt im yc ob ac te ria ls 28 1. 12 % J0 1D :O th er b et a- la ct am an tib ac te ria ls 18 8 7. 54 % J0 1C E :B et a- la ct am as e se ns iti ve p en ic ill in s 1 0. 04 % J0 5: A nt iv ira ls fo r s ys te m ic us e 1 0. 04 % J0 1F :M ac ro lid es , lin co sa m id es a nd st re pt og ra m in s 42 1. 68 % J0 1C R :C om bi na tio ns o f pe ni ci lli ns , i nc l. be ta -la ct am as e in hi bi to rs 15 0. 60 % J0 6: Im m un e se ra a nd im m un og lo bu lin s 4 0. 16 % J0 1G :A m in og ly co si de an tib ac te ria ls 5 0. 20 % J0 1D B :F irs t-g en er at io n ce ph al os po rin s 3 0. 12 % J0 1M :Q ui no lo ne an tib ac te ria ls 50 2. 00 % J0 1D D :T hi rd -g en er at io n ce ph al os po rin s 14 2 5. 69 % J0 1R :C om bi na tio ns o f an tib ac te ria ls 9 0. 36 % J0 1D E 36 1. 44 % J0 1X :O th er a nt ib ac te ria ls 1 0. 04 % J0 1D H :C ar ba pe ne m s 7 0. 28 % J0 2A :A nt im yc ot ic s fo r sy st em ic u se 2 0. 08 % J0 1F A :M ac ro lid es 41 1. 64 % J0 4A :D ru gs fo r t re at m en t of tu be rc ul os is 28 1. 12 % J0 1F F: Li nc os am id es 1 0. 04 % J0 5A :D ire ct a ct in g an tiv ira ls 1 0. 04 % J0 1G B :O th er a m in og ly co si de s 5 0. 20 % J0 6A :Im m un e se ra 1 0. 04 % J0 1M A :F lu or oq ui no lo ne s 50 2. 00 % J0 6B :Im m un og lo bu lin s 3 0. 12 % J0 1R A :C om bi na tio ns o f an tib ac te ria ls 9 0. 36 % J0 1X X :O th er a nt ib ac te ria ls 1 0. 04 % J0 2A B :Im id az ol e de riv at iv es 1 0. 04 % J0 2A C :T ria zo le d er iv at iv es 1 0. 04 % J0 4A B :A nt ib io tic s 8 0. 32 % J0 4A K :O th er d ru gs fo r tre at m en t o f t ub er cu lo si s 12 0. 48 % J0 4A M :C om bi na tio ns o f d ru gs fo r t re at m en t o f t ub er cu lo si s 8 0. 32 % J0 5A B :N uc le os id es a nd nu cl eo tid es e xc l. re ve rs e tra ns cr ip ta se in hi bi to rs 1 0. 04 % 70 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients J0 6A A :Im m un e se ra 1 0. 04 % J0 6B B :S pe ci fic im m un og lo bu lin s 3 0. 12 % L = A nt in eo pl as tic an d im m un om od ul at in g ag en ts 4 0. 16 % L0 1: A nt in eo pl as tic a ge nt s 1 0. 04 % L0 1X :O th er a nt in eo pl as tic ag en ts 1 0. 04 % L0 1X X :O th er a nt in eo pl as tic ag en ts 1 0. 04 % L0 3: Im m un os tim ul an ts 1 0. 04 % L0 3A : I m m un os tim ul an ts 1 0. 04 % L0 3A A :C ol on y st im ul at in g fa ct or s 1 0. 04 % L0 4: Im m un os up pr es sa nt s 2 0. 08 % L0 4A :Im m un os up pr es sa nt s 2 0. 08 % L0 4A A :S el ec tiv e im m un os up pr es sa nt s 1 0. 04 % L0 4A X :O th er im m un os up pr es sa nt s 1 0. 04 % M = M us cu lo - sk el et al s ys te m 54 2. 17 % M 01 :A nt iin fla m m at or y an d an tir he um at ic p ro du ct s 34 1. 36 % M 01 A : A nt iin fla m m at or y an d an tir he um at ic pr od uc ts , n on -s te ro id s 34 1. 36 % M 01 A B :A ce tic a ci d de riv at iv es an d re la te d su bs ta nc es 10 0. 40 % M 02 :T op ic al p ro du ct s fo r jo in t a nd m us cu la r p ai n 1 0. 04 % M 02 A :T op ic al p ro du ct s fo r jo in t a nd m us cu la r p ai n 1 0. 04 % M 01 A E :P ro pi on ic a ci d de riv at iv es 2 0. 08 % M 03 :M us cl e re la xa nt s 2 0. 08 % M 03 A :M us cl e re la xa nt s, pe rip he ra lly a ct in g ag en ts 2 0. 08 % M 01 A G :F en am at es 22 0. 88 % M 04 :A nt ig ou t p re pa ra tio ns 17 0. 68 % M 04 A :A nt ig ou t pr ep ar at io ns 17 0. 68 % M 02 A A :A nt iin fla m m at or y pr ep ar at io ns , n on -s te ro id s fo r to pi ca l u se 1 0. 04 % M 03 A C :O th er q ua te rn ar y am m on iu m c om po un ds 2 0. 08 % M 04 A A :P re pa ra tio ns in hi bi tin g ur ic a ci d pr od uc tio n 16 0. 64 % M 04 A C :P re pa ra tio ns w ith n o eff ec t o n ur ic a ci d m et ab ol is m 1 0. 04 % N = N er vo us sy st em 22 6 9. 06 % N 01 :A ne st he tic s 2 0. 08 % N 01 A :A ne st he tic s, g en er al 1 0. 04 % N 01 A X :O th er g en er al an es th et ic s 1 0. 04 % N 02 :A na lg es ic s 17 9 7. 18 % N 01 B :A ne st he tic s, lo ca l 1 0. 04 % N 01 B B :A m id es 1 0. 04 % N 03 :A nt ie pi le pt ic s 13 0. 52 % N 02 A :O pi oi ds 29 1. 16 % N 02 A A :N at ur al o pi um a lk al oi ds 11 0. 44 % 71 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med N 04 :A nt i-p ar ki ns on d ru gs 4 0. 16 % N 02 B :O th er a na lg es ic s an d an tip yr et ic s 15 0 6. 01 % N 02 A B :P he ny lp ip er id in e de riv at iv es 12 0. 48 % N 05 :P sy ch ol ep tic s 17 0. 68 % N 03 A :A nt ie pi le pt ic s 13 0. 52 % N 02 A X :O th er o pi oi ds 6 0. 24 % N 06 :P sy ch oa na le pt ic s 7 0. 28 % N 04 A :A nt ic ho lin er gi c ag en ts 2 0. 08 % N 02 B E :A ni lid es 15 0 6. 01 % N 07 :O th er n er vo us s ys te m dr ug s 4 0. 16 % N 04 B :D op am in er gi c ag en ts 2 0. 08 % N 03 A B :H yd an to in d er iv at iv es 2 0. 08 % N 05 A :A nt ip sy ch ot ic s 5 0. 20 % N 03 A E :B en zo di az ep in e de riv at iv es 1 0. 04 % N 05 B :A nx io ly tic s 10 0. 40 % N 03 A F: C ar bo xa m id e de riv at iv es 1 0. 04 % N 05 C :H yp no tic s an d se da tiv es 2 0. 08 % N 03 A G :F at ty a ci d de riv at iv es 4 0. 16 % N 06 A :A nt id ep re ss an ts 3 0. 12 % N 03 A X :O th er a nt ie pi le pt ic s 5 0. 20 % N 06 D :A nt i-d em en tia d ru gs 4 0. 16 % N 04 A A :T er tia ry a m in es 2 0. 08 % N 07 C :A nt iv er tig o pr ep ar at io ns 4 0. 16 % N 04 B A :D op a an d do pa de riv at iv es 2 0. 08 % N 05 A D :B ut yr op he no ne de riv at iv es 3 0. 12 % N 05 A X :O th er a nt ip sy ch ot ic s 2 0. 08 % N 05 B A :B en zo di az ep in e de riv at iv es 10 0. 40 % N 05 C D :B en zo di az ep in e de riv at iv es 2 0. 08 % N 06 A A :N on -s el ec tiv e m on oa m in e re up ta ke in hi bi to rs 2 0. 08 % N 06 A B :S el ec tiv e se ro to ni n re up ta ke in hi bi to rs 1 0. 04 % N 06 D A :A nt ic ho lin es te ra se s 4 0. 16 % N 07 C A :A nt iv er tig o pr ep ar at io ns 4 0. 16 % 72 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients R = R es pi ra to ry sy st em 16 1 6. 46 % R 01 :N as al p re pa ra tio ns 14 0. 56 % R 01 A :D ec on ge st an ts a nd ot he r n as al p re pa ra tio ns fo r t op ic al u se 14 0. 56 % R 01 A D :C or tic os te ro id s 14 0. 56 % R 03 :D ru gs fo r o bs tru ct iv e ai rw ay d is ea se s 57 2. 29 % R 03 A :A dr en er gi cs , in ha la nt s 56 2. 25 % R 03 A C :S el ec tiv e be ta -2 - ad re no re ce pt or a go ni st s 19 0. 76 % R 05 :C ou gh a nd c ol d pr ep ar at io ns 90 3. 61 % R 03 B :O th er d ru gs fo r o bs tru ct iv e ai rw ay di se as es , i nh al an ts 1 0. 04 % R 03 A L: A dr en er gi cs in c om bi na tio n w ith an tic ho lin er gi cs in cl . tri pl e co m bi na tio ns w ith co rti co st er oi ds 37 1. 48 % R 05 C :E xp ec to ra nt s, e xc l. co m bi na tio ns w ith c ou gh su pp re ss an ts 87 3. 49 % R 03 B A :G lu co co rti co id s 1 0. 04 % R 05 D :C ou gh su pp re ss an ts , e xc l. co m bi na tio ns w ith ex pe ct or an ts 3 0. 12 % R 05 C B :M uc ol yt ic s 86 3. 45 % R 05 D A :O pi um a lk al oi ds a nd de riv at iv es 3 0. 12 % S = S en so ry or ga ns 54 2. 2% S 01 :O ph th al m ol og ic al s 23 0. 92 % S 01 A :A nt iin fe ct iv es 15 0. 60 % S 01 A A :A nt ib io tic s 5 0. 20 % S 02 :O to lo gi ca ls 31 1. 24 % S 01 E :A nt ig la uc om a pr ep ar at io ns a nd m io tic s 7 0. 28 % S 01 A E :F lu or oq ui no lo ne s 8 0. 32 % S 01 X :O th er op ht ha lm ol og ic al s 1 0. 04 % S 01 E C :C ar bo ni c an hy dr as e in hi bi to rs 3 0. 12 % S 02 B :C or tic os te ro id s 31 1. 24 % S 01 E D :B et a bl oc ki ng a ge nt s 4 0. 16 % S 01 FA :A nt ic ho lin er gi cs 2 0. 08 % S 01 X A :O th er op ht ha lm ol og ic al s 1 0. 04 % S 02 B A :C or tic os te ro id s 31 1. 24 % V = V ar io us 31 1. 24 % V 03 :A ll ot he r t he ra pe ut ic pr od uc ts 12 0. 48 % V 03 A :A ll ot he r t he ra pe ut ic pr od uc ts 12 0. 48 % V 03 A E :D ru gs fo r t re at m en t of h yp er ka le m ia a nd hy pe rp ho sp ha te m ia 12 0. 48 % V 06 :G en er al N ut rie nt s 19 0. 76 % V 06 D :D ie t f or m ul at io ns fo r tre at m en t o f o be si ty 19 0. 76 % V 06 D C :C ar bo hy dr at es 19 0. 76 % n ot e: A p at ie nt m ay b e pr es cr ib ed o ne o r m or e th an o ne d ru g fr om le ve l 2 , l ev el 3 an d le ve l 4 c at eg or ie s P er ce nt ag es g iv en w ith r es pe ct to th e to ta l s am pl e si ze o f t he p at ie nt 73 Czeresna H. Soejono Acta Med Indones-Indones J Intern Med more severely ill with higher number of co- morbidities.11 Patients with higher number of co-morbidity will have higher risk of multiple medications. Special consideration should be given to the use of ranitidine for gastrointestinal symptom and diagnosis in digestive system. It was prescribed as much as 33.0% of all medications (the highest number of drug) whereas Sheth (2020) also found the same observation that ranitidine was the most common medication prescribed in tertiary hospital.12 From geriatrics point of view of H2 receptor antagonist class, this drug has potentially serious side effect for the elderly, namely confusion, hallucination, and arrhythmia.13,14 As the clearance of this drug becomes slower in geriatric population compared to the young ones (0.58 SD 0.19 mL/hr vs 1.11 SD 0.12 mL/hr, p<0.0002); the elimination of half life is longer in elderly than the young ones (4.66 SD 1.23 hr vs 2.50 SD 0.75 hr, p<0.01), and the reached maximum concentration in elderly is higher than in younger patients (1647.7 [1332.0 – 2079.0] ng/mL vs 573.7 [419.2 – 905.7] ng/mL, p<0.01) made this aged population was likely to have this risk of side effects.15 Clinicians as well as the management has to be aware of this situation in planning for the gastrointestinal medications. Omeprazole that was also prescribed quite often in this observation might provide better option. Evaluating the connection between most frequent drugs being prescribed (normal saline, ranitidine, paracetamol, ceftriaxone, o m e p r a z o l e , a n d a m l o d i p i n e ) w i t h t h e prevalence of diagnosis (malignancies, infection, hemodynamic disturbances, digestive diseases) or presenting symptoms (respiratory complaints, gastrointestinal symptoms, neurological, pain, fatigue), the drug pattern being used was still coherent. Kurt (2019) reported a slightly different distribution of diseases among those with polypharmacy attending family medicine outpatient clinic; hypertension (71.66%), diabetes mellitus (40.00%), hyperlipidemia (31.25%), depression (18.75%), and hypothyroidism (17.91%) were the top five diagnosis; cancer was in number six (8.75%).16 This variation was due to the difference in disease pattern at outpatient clinic compare to that of in inpatient hospital wards.17 In this observation, it was found that there was no distribution differences of drugs being prescribed according to sex or age group. Santalucia et al.10 reported the similar result, although more drugs were given to men compared to women (5.38 SD 3.0 vs 5.08 SD 2.8; p<0.0030). Morgan18 also found similar result, although the community dwelling elderly women were at 16% higher odds of receiving inappropriate prescriptions than men (adjusted OR 1.16, 95% CI 1.12-1.210. The trend of polypharmacy according to age group was not found in this report as well.10,19 The older the patients become does not necessarily mean they have to use more medications. The median number of chronic diseases per patient in this research was three; subjects then grouped as having more than three diseases (higher level of multimorbidity) and three or less than three diseases (lower level of multimorbidity). There was a significant difference between these two groups in regard to the occurance of polypharmacy. Percentage of those with polypharmacy in the first group was higher than the second group (52.7% vs 30.4%) and the percentage of those without polypharmacy was higher in the second group than the first group (69.6% vs 47.3%), p: 0.000; OR 2.554 (95% CI 1.724-3.783). The same finding were reported by Kurt16 and Ramos17. Kurt16 reported that the older the subjects were the more likely they had higher ratio of chronic diseases per age group which was concordance with the number of medications. While Ramos17 observed, also those with history of hospitalization in the previous year were more likely to have > five drugs at the same time, compare to those without history of prior hospitalization (32% [95% CI 27.7;37.7 vs 16.3 [95% CI 15.0-17.8]). It was as expected that those with higher number of chronic diseases were more likely to have more medications and had higher risk of being hospitalized due to acute insult. As a whole, the top ten list of medication (NaCl, paracetamol, ranitidine, ceftriaxone, omeprazole, N-acetyl cysteine, propulsive, amlodipine, HMG CoA reductase inhibitor, 74 Vol 53 • Number 1 • January 2021 Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients ACE inhibitor) were coherent with the top ten list of diagnosis (malignancies, infections, cardiovascular, hemodynamic disturbances, digestive diseases, metabolic encephalopathy, neurologic diseases, musculoskeletal and skin diseases, hematologic diseases) or ten most frequent primary complaints (respiratory system, gastrointestinal system, neurology, pain, fatigue, trauma, cardiology, musculoskeletal and skin, reproduction and urinary system, fever). In a more detailed perspective while malignancies was number one diagnosis but it did not necessarily put cytotoxic drugs (chemotherapy agents) as the most frequent medications that should be prescribed. It was expected that not all malignancy cases in ED will be treated with chemotherapy; but treating dehydration or provide vascular access were essential. Malignancy cases often come to ED due to pain of fever secondary from infection that also need antibiotics and or paracetamol. In this observation, it was also found that (Table 3) diet formulation for the treatment of obesity prescribed in ED which actually was not essential for emergency situation; clinicians should be aware of this and be advised not to execute unnecessary non-emergency medications in an emergency unit. conclUsIon The prevalence of polypharmacy was 57.6%; percentage of polypharmacy were equally distributed between women and men, as well as between younger and older age groups. The most frequent drugs used were sodium chloride, followed by paracetamol, ranitidine, ceftriaxone, omeprazole, NAC, propulsive, amlodipine, HMG CoA reductase inhibitor, and ACE inhibitor. The presence of polypharmacy in those with > 3 diseases was significantly higher than those with < 3 chronic diseases. The most frequently prescribed medications were concordant with the most common diagnosis and or primary complaints, despite the concern regarding the use of ranitidine and diet formulation for the treatment of obesity in the emergency department. AcknoWlEDgMEnts Special thank you to Rahmi Istanti, SKM, MARS and dr. Yulian Huningkor for your help in preparation and tidy up up the data. conFlIct oF IntErEst Authors declare no conflict of interest. rEFErEncEs 1. BAPPENAS, BPS, UNFPA. Proyeksi penduduk Indonesia (Indonesia population projection) 2015- 2045. Hasil SUPAS 2015. Jakarta: Bappenas; Agustus 2018. 2. van Seben R, Smorenburg SM, Buurman BM. A qualitative study of patient-centered goal-setting in geriatric rehabilitation: patient and professional perspectives. Clinical Rehabilitation. 2019; 33(1):128– 40. 3. Morandi A, Bellelli G, Vasilevskis EE. 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