The domino effect of a GP visit
ver the years, many have told me that personally they would never dream of seeing their doctor – unless it was really necessary. There is more to this than the commendable desire not to take advantage of our “free” health service. Rather, there is an element of mistrust, the fear that once doctors get you in their clutches they can make things worse rather than better. These misgivings are entirely reasonable so, with the new year beckoning, those wondering what “healthy” resolution to make might consider rationalising the medicines they are taking in light of the phenomenon of the “prescribing cascade”.
Consider, for example, a man in his late seventies, fit and active, “routinely prescribed” (like so many of his age group) a cholesterol lowering statin. Two months later, he consults his doctor with muscular aches and pains for which, in the absence of any obvious cause, he is advised to take the anti-inflammatory ibuprofen. Two months after this, summoned to the surgery for a flu jab, the nurse finds his blood pressure to be raised, warranting a daily dose of the antihypertensive thiazide diuretic, bendrofluazide.
Another three months passes and he is woken at night with an excruciatingly painful big toe, correctly diagnosed as an acute attack of gout warranting treatment with allopurinol. When he returns a few weeks later, the doctor checks his blood sugar, previously normal, but finds it to be raised, resulting in a prescription for the antidiabetic drug metformin. Soon after, he develops diarrhoea for which, again in the absence of any obvious cause, he is advised to take loperamide.
At this point he inquires: “Why do so many things seem to have gone wrong recently?” but is reassured that, at his age “these things happen”. And anyhow, gratifyingly, each of his several medical problems have been satisfactorily dealt with. But were one to scrutinise those several consultations in any detail, it is possible to discern a cascade. The statins were responsible for the muscular aches and pains. Their treatment with anti-inflammatories can raise the blood pressure, hence the prescribing of the antihypertensive thiazide diuretic. This can raise both the uric acid level (hence the attack of gout) and blood sugar (hence the diabetes). The treatment for the latter with metformin caused the diarrhoea – hence the loperamide.
This might seem an extreme case but it is possible to identify in any lengthy list of drugs one or more that have been prescribed to counter the adverse effects of another. “The prescribing cascade is always preventable,” notes Paula Rachon, a professor of medicine, “by always considering whether any new medical condition might be the result of an existing treatment.” Quite so.
All in your head
Finally, and on a lighter note, there is much to be said for standing on one’s head in increasing the blood supply to the brain, which a 90-year-old yoga devotee maintains keeps her young (in mind) and agile. The increased blood flow to the scalp is also reported to promote hair growth in the bald – best achieved by hanging upside down with one’s legs hooked over a bar. “My bald patch was reduced by a third of its original size, and I regained almost half of the hair I lost,” claims a 52-year-old sales executive from Henley.
Head-standing is also an effective cure for a stitch by taking the pressure off the ligaments that keep the gut in place. It can also be of value for those with episodes of rapid heartbeat as for a woman whose pulse would regularly shoot up to 300 beats a minute, warranting her admission to hospital. On one occasion, the doctor in A&E suggested she try standing on her head and “within a minute” her heart rate had returned to normal. This technique worked well for the next dozen or so occasions until eventually she had a curative ablation procedure.
Always consider whether any new condition might be the result of an existing treatment