Pre­scrip­tion Ad­dic­tion

When Medicines Do More Harm

Reader's Digest Asia Pacific - - Front Page -

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.

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