When Medicines Do More Harm
IT WAS THE MIDDLE OF THE NIGHT and Judy Graham, a 67-year-old grandmother from Sydney, got out of bed to go to the bathroom. All of a sudden, the dark room swirled around her. She crashed to the floor, smashing her jaw into the bedside table.
Waking up in a pool of blood as her worried husband, Roy, called an ambulance, Judy had no idea why she’d fainted. She was healthy and active, though she’d recently seen her doctor for a new script for amlodipine to try to bring down her bothersome high blood pressure.
In the emergency department, the doctors were concerned that her blood pressure was abnormally low – just 105 over 68 (the Australian Heart Foundation recommends the top number, the systolic blood pressure, should be 120 for people of Judy’s age). It was the low blood pressure that had caused her to pass out as she stood up.
Judy Graham had joined a very large group of older people whose medicines were doing them more harm than good.
AS YOU GET OLDER, your medicine cabinet can begin to resemble a pharmacy.
But today, many researchers are asking: do you – or do many people 55 and older – really need quite so many medications?
Professor Sarah Hilmer, a geriatric pharmacologist who works at Royal North Shore Hospital in Sydney, says that over-prescribing for older people is a major problem. “There are two issues: medicines work differently in our bodies as we age – as we get older, our bodies generally have less muscle and more fat, we often shrink in size and our liver and kidneys don’t work so well, so we often don’t need the same dose as we did when we were younger.
“The bottom line: if you’re taking 12 pills a day, you’re taking too many.” DR CARA TANNENBAUM, pharmacy profes sor
“Also, we’re more likely to develop multiple diseases, each of which requires drugs that then might interact with each other,” she says.
Or the medication might not be right for you at all.
Too often, doctors either don’t follow up to ensure that prescriptions are well-tolerated, or continue to refill old prescriptions without considering whether those drugs are still – or were ever – necessary.
Judy Graham’s blood pressure medication dose was adjusted right away, bringing her blood pressure to a healthy level without the dizziness. But she’d broken her jaw and lost two teeth, and faced several weeks of painful recovery with her mouth wired shut.
As Judy learned, some of the most common medicines prescribed can also be among the most problematic.
Blood pressure medication
Combining medications to lower blood pressure and cholesterol does reduce deaths from heart disease, says a recent large global study. In fact, more than one million Australians who are at high risk of a heart attack or stroke are not being prescribed these lifesaving medications, according to another recent study of older Australians.
However, people often continue to be prescribed high doses of medication even after their blood pressure reaches optimum levels. And overtreatment, especially in older people, can lead to dizzy spells, confusion, falls, even severe kidney problems.
Older age can lead to a condition called ‘autonomic neuropathy’, explains Hilmer. This means it’s more likely their blood pressure will drop when they stand up. In fact, studies show that if you stop your blood pressure medications in older age, you have a 50 per cent chance of having normal blood pressure for up to five years.
One group is particularly at risk of adverse effects: people with diabetes. Doctors are more likely to treat high blood pressure more aggressively in people with diabetes because they are more at risk of heart disease and stroke. But a recent Cochrane Review, which is the gold standard of assessing the credibility of healthcare research, looked at all the evidence from around the world and found that lowering blood pressure too much resulted in a significant increase in the number of serious adverse events in people with diabetes.
Another Swedish study analysed cases in the national database of people with diabetes who were taking
blood pressure medication. Not all of them actually had high blood pressure. In such patients, the researchers found that taking blood pressure-lowering medications actually increased the risk of death from heart disease and stroke by 15 per cent. “The ability to deal with drops in blood pressure seems to be impaired in people with diabetes,” explains chief researcher Dr Mattias Brunström.
Statins to lower cholesterol
The use of statins has increased dramatically and they are now one of the most commonly prescribed drugs in the world. One Australian study found statins are being taken by more than 40 per cent of people over 65.
But many are taking statins for prevention of a disease they have a vanishingly small risk of getting. Statins are a years-long strategy to reduce the build-up of cholesterol-laden plaque in your blood vessels. If you have no current signs of build-up, and you’re older, statins might give you little to none of this long- term preventive benefit.
Many people experience muscle aches and weakness due to statins. There is also a 50 per cent risk of newonset diabetes, according to a large 2015 Finnish study, which showed that the more statins people took, the lower their insulin sensitivity and insulin secretion. Another trial showed that statins might affect your memory: it found that people with Alzheimer’s experienced an improvement in cognitive function when they stopped their statin.
Hilmer remembers one recently retired 70 year old, for example, whose memory loss and muscle aches were so great when he started his statin that he could see a difference in his scrabble game and could no longer finish his usual 18 holes of golf. His cardiologist told him he really did need to be on the medication, so they cut the dose in half, and then in half
again. His thinking quickly returned to normal, his muscle aches resolved, and now he’s back winning most games of scrabble and enjoying time on the fairway. Though rare, statins have recently been implicated in autoimmune muscle disorders such as necrotising polymyositis, the devastating condition that dramatically weakens muscles. Statins have also been implicated in other muscle ailments.
According to Hilmer, whose studies have shown the benefits of statins are unclear in older people who have never had a heart attack or stroke, the risk of side effects is common. “If you’re taking a statin for primary prevention into your eighties – that is, to prevent your first ever heart attack or stroke – then you should probably stop, it’s not worth the side effects,” she says.
Insulin for diabetes
Those people with type 1 diabetes and many with later-stage type 2 rely on insulin to keep their blood glucose under control. It can be essential for anyone who has had an A1c level (a measure of glucose in the bloodstream) at nine or above for an extended period.
When people take more insulin than necessary, they can develop hypoglycaemia – meaning that they have too little glucose circulating in their bloodstreams. This can lead to confusion and other cognitive impairments, falls, coma and even death.
As it takes decades for the problems of poorly controlled diabetes to emerge, such as blindness or kidney failure, it’s important to weigh up the benefits of taking insulin versus the very real risk of a hypoglycaemia attack.
And yet one large 2015 US study by Dr Jeremy Sussman, an internal medicine specialist, and colleagues found that older patients with diabetes rarely had their insulin dosages adjusted,
even when their blood-glucose levels were low enough to put them in the danger zone.
What counts as dangerously low? An A1c under 6 is risky, according to Sussman. The safe zone in his study is between 6.5 and 7.5. “As people get older, a small amount off can become more dangerous,” he says. A too-low A1c from over-treatment is an immediate danger.
Proton pump inhibitors for indigestion and acid reflux
Proton pump inhibitors ( PPIs) are often recommended for the prevention of ulcers, gastrointestinal bleeding, and to reduce acid reflux due to excess stomach acid – which they block so effectively that their popularity has exploded worldwide, with more than 19 million prescriptions in Australia in 2013–14.
But they’re too effective to be used so freely. Stomach acid is necessary to break down vitamins and minerals so the body can utilise them. After years of taking PPIs, people can develop severe deficiencies.
PPIs are particularly risky for people aged 65 and older. Long-term deficiencies can leave the bones weak and can lead to fractures. And a 2016 German study links PPI use with an increased risk of dementia in the elderly, apparently due to PPIs blocking vitamin B12 absorption.
One recent Australian study found up to 60% of GPs had made no attempt to reduce patients’ doses over time, with almost half of people on PPIs having no clear reason for taking them.
“PPIs are an extremely commonly prescribed medication which people are left on because they are regarded as benign,” says gastroenterologist Dr Katherine Ellard. “If you have heartburn and reflux, you might well be able to get away with over- thecounter products such as Gaviscon or Mylanta. And losing weight, avoiding spicy food and keeping clear of alcohol and coffee can be other ways of managing heartburn without medication.”
When an antacid is necessary, try a short course of a histamine-2 blocker such as famotidine (Pepcid) or ranitidine (Zantac).
If you’ve been on a PPI for a while, get in touch with your doctor about weaning yourself off them.
Opioids for pain
Anne Gleeson first started experiencing terrible, incurable pain in the
“It’s important not to stop or change your medication without talking to your doctor first.” DR ROBYN LINDNER, Choosing Wi sely Aust ral ia
weeks after her second knee replacement six and a half years ago. She was eventually diagnosed with complex regional pain syndrome, a pain disorder for which there is no cure. With her sympathetic nervous system in overdrive, the lightest touch of a blanket or trouser leg can cause unbearable pain. “On a scale of one to ten, it’s often a seven or eight. Some days it’s a four, and that’s a good day,” she says.
There are only a few drugs that are effective in treating nerve pain such as Anne’s. For months she tried opioid patches, but they gave her bad hallucinations. Then her doctor recommended a new drug called Lyrica (pregabalin). Soon after she started taking the drug, she was sitting in her living room when her arm started to twitch and her vision to blur. Her legs began to shake uncontrollably and then she fell back. She had a full-blown seizure that put her in hospital for ten days.
The problem had been the combination of the two drugs. But when she tried to come off her opioid, the withdrawal symptoms were extreme, causing her to violently vomit, shake and sweat. “I just couldn’t get off the bed,” she recalls.
The overuse of opioids to control pain is a major problem around the world. Not only do they cause side effects such as constipation and impaired memory, but you can develop a tolerance to them – meaning you need more and more to feel the same relief. While opioids work very well for acute (short-lasting pain) and pain caused by cancer, studies have shown there is minimal evidence that they work for long-term, chronic pain. In fact, the risk of harm is high. Despite this, scripts for opioids such as oxycodone (OxyContin) in Australia ballooned from over 2.3 million
in 1992 to nearly 7 million in 2007.
“If you are going to try an opioid for pain you should have a low dose for a defined period with a defined treatment goal,” says Hilmer.
Now Anne’s on a different drug, gabapentin (Neurontin), and she uses other strong pain killers instead of opioids.
But the best therapy may not be another pill, but cognitive behavioural therapy, which has been shown in recent studies to be an integral part of helping people to lessen their experience of pain.
Sedatives for insomnia
Some of the more recent anti-insomnia drugs, including zolpidem (Ambien/Stilnox), can cause cognitive problems including amnesia. In February 2008 the Australian Therapeutic Goods Administration attached a boxed warning to zolpidem (Stilnox), stating that it “may be associated with potentially dangerous complex sleep-related behaviours that may include sleep-walking, sleep-driving …” Other sedatives in this family, such as eszopiclone (Lunesta) and zaleplon (Sonata), have been reported to cause the same types of symptoms.
The drugs tend to have a greater effect on women and the elderly aged 80 and over who are, for example, more likely to be involved in car collisions in the days after taking zolpidem at night. They are also linked to increases in falls.
In addition, a 2015 Taiwanese study found that zolpidem and similar drugs appeared to increase the risk of dementia in the elderly.
“It’s important that people understand for every medicine or test there is a risk and a benefit. Most of the time that benefit far outweighs the risks – but for medicines there is always a risk they will have side effects, and when you take multiple medicines there is always the risk that you will multiply the chances,” says Dr Robyn Lindner of Choosing Wisely Australia. Medical colleges and consumer groups collaborate in Choosing Wisely Australia, an initiative attempting to get doctors and patients to think twice when considering tests, treatments and procedures where evidence shows they provide no benefit or, in some cases, lead to harm.
“Your doctor may not know everything you’re taking – you as the person taking the medicines really have the best visibility,” says Lindner. “We encourage people to keep a list, and to have a periodic review to make sure they’re not doubling up.”
While you should never stop taking a medication or change your dosage without medical guidance, always insist on discussing the risks versus the benefits of every medicine with your GP and pharmacist. And ask whether your prescriptions continue to be right for you as you grow older.
Stay informed to ensure your prescription drugs aren’t doing you more harm than good.