Posts Tagged drug side effects

Deprescribe — too many medications

bottle_of_medsMany patients take too many medications which leads to unnecessary side effects, drug interactions and high cost.  Yet physicians sometimes fight just to get patients to take necessary medications.  Two examples:

  1. Provider:  How many medications are you taking?
    Patient:  Including vitamins I think fifteen.
    Provider:  What? I only have two medications on my list.
    Patient:  I restarted all the medications I was taking before you hospitalized me plus all the new prescriptions from when I left the hospital and I added some vitamins.
  2. Patient:  I stopped that medication because I thought it was causing my hair to fall out.
    Provider:  Your heart medication does not cause hair to fall out.  And, even if it did you could die without it.

The medications you take should be reviewed at each visit so you and the provider consider which are truly needed and why.  The provider who gives the patient a prescription is responsible to make sure there is no interaction or duplication with ongoing treatment.  Yes, that means cardiologists and dentists also.  A proactive patient should simply ask, “Is that new medication compatible with all of my existing medications and does it replace one of the existing medications?

The highest risk situation for evaluation of medications happens when alternate providers become involved.  Like a hospital doctor, an ER doctor or a specialist.  They tend to add medications without fully considering the existing medications, often thinking the primary provider will resolve any drug issues — too bad when a fill-in primary provider steps into the mix.

An article in the Washington Post January 28, 2017 by Dr. Ranit Mishori advises the following questions for providers and patients to consider together about medications:

● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?

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Over prescribing — high risk for the elderly

hugsnotdrugs

Elderly patients are taking too many drugs.  And, in most cases the drugs can be stopped.  This surprising idea was highlighted by Dr. Ezekiel J. Emanuel in his New York Times article 11/22/15.  He backed up his statements with a study from 2010 (JAMA).  The figures that follow are from that study.

The first figure is the logic diagram for stopping medications in elderly patients who have several chronic diseases.  The second figure is the list of medications that were stopped in the study.  Only 2% of the stopped medications eventually had to be restarted.  The cost savings alone is huge and the reduction in the risk of side effects is likewise tremendous.  “Less is more”.

Health care providers often prescribe drugs intended for younger healthier patients to older sicker patients.  Often the drug testing originally done to approve drugs excludes older sicker patients due to the risks of side effects.  A drug might add many years of life to a 50 year old but that’s not likely for an 80 year old with multiple problems.   In fact, over medicating elderly patients may hasten death — this has been proven in many studies.

Dr Ezekiel suggests asking the following questions to the health care providers who prescribe medications, tests or treatments to elderly patients (or perhaps any patients):

  1. What difference will it make?
  2. How much improvement is expected?
  3. How likely and severe are the side effects?

Evaluate the answers carefully, if the answers are: small difference, not much improvement, and fairly likely side effects then perhaps that drug, test or treatment is not needed.

Dr. Emanuel favors the advice of teaching hospital doctors like him, but it’s just not practical or necessary for patients to get a university consultation.  Stopping medications is not rocket science.  As the graphic says, it may be better for many elderly patients to get “hugs not drugs“.

 

Figure 1

drugstop

 

 

Figure 2

medsstopped

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The Perils of Over-Treatment — diabetes and hypertension

excessToo much treatment is dangerous just like too little treatment.  Treating blood pressure too early or too aggressively increases the risk of death.  Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and leads to broken bones from falling.

In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure.  Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.

This is not rocket science.  Imagine a blood pressure medication that could lower the blood pressure to any level.  Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous.  Same for blood sugar.

Sometimes this problem is called “treating the test“.  In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness.  Hypertension and diabetes are good examples but this happens with lots of other conditions.

Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics.  It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time to do either.

Most drugs have a “therapeutic windowopenwindow.  As long as the window is open the patient gets benefit.  But, the window closes due to side effects and advanced age.

If a person is over 80 or in poor health excessive medical treatment is a substantial risk.  In this group even the thought of a low cholesterol diet is foolhardy.   It’s all about risks and benefits.

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Doctors and Warfarin — patient expectations

rat_bw


Bill(*) had a really bad headache and died before he could call 911
.  He died of a complication of warfarin which he was taking to prevent blood clots.  Instead, the best intentions to prevent a stroke lead to uncontrolled bleeding in the brain, high pressure inside the skull and death.

Warfarin and other anticoagulants are necessary medications but also dangerous medications.   People take the medications because the risk of blood clots, for them, is higher than the risk of anticoagulation.   The last thing a patient wants is for drug management errors to tip balance so the risk of the medication is too high.

So, what are the expectations of people who take warfarin?  What do they expect of their providers?  What do the providers expect of them?

  1. Patients expect providers to follow drug guidelines to the letter
  2. Providers expect patients to follow instructions and learn about warfarin
  3. Patients want to be in the loop — meaning the risks are high so they want to be in a position to make sure the necessary communication happens and dose adjustments make sense.
  4. Providers need to be able to contact patients and expect positive feedback — “message received, will change dose to ___ as directed”
  5. Patients expect a consistent process no matter the day of the week or which provider is on call.
  6. Above all, patients expect adequate prevention and minimum risk.

Here are several marks of quality warfarin management:

  • The same day of drawing lab (INR)  the patient is informed 1) the result  2) the change in dose and 3) the date of the next lab.  Finger-stick methods with quick results allow some offices to provide instructions before the patient leaves the office.
  • The patient is asked to keep a record of results and instructions.  And, to “read back” the instructions.  Thus the provider knows the patient got the right message.
  • The patients have the phone number to call for any evidence of abnormal bruising or bleeding.  They should expect to get lab tested or go to the emergency room.
  • There is no impediment to getting the warfarin prescription refilled when needed.
  • Providers use computer applications or paper tables to select the correct warfarin dose.  Only if there are unusual problems do they deviate from established guidelines.
  • If the INR is out of range the dose is changed and the INR is rechecked within a week — even if the patient was on a monthly lab routine.
  • The day the INR is checked patients do not take the usual warfarin dose until the results are available.
  • Providers never say “just keep taking the same dose unless we call you”.   That is a recipe for disaster if a lab test is lost or sent to the wrong provider.
  • The lab the patient uses is open 7 days a week.
  • Providers instruct patients to follow a consistent diet so the amount of vitamin K in the diet is fairly constant.  A sudden drop in vitamin K intake causes the INR to rise and bleeding risk to increase.

Back to the case of Bill.  He forgot to get his INR checked on Friday and nobody called him to check why.  He knew the lab was not open on the weekend.  The nosebleed was unusual but not too bothersome — besides, his doctor was not on call and he did not know who to call.  He took a slight fall and bumped his head – he didn’t think small head injuries were risky.  He had a good memory but sometimes forgot how many warfarin pills to take on Saturday so he took 2.  Wrong, wrong and wrong. The outcome might be better if the medical process was better and if patient education was better.


(*) Bill’s case is not real but such deaths have been reported.  It is true warfarin is related to rat poison.

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Drug Side Effects — could it be the medication?

Dino xing

 The physician who does not carry a smart phone to look up drug side effects is a dinosaur soon to be extinct.

Drug side effects can be common, rare,  severe or mild.  But, the number of reported drug side effects is so large the human brain can not remember them all.  When a patient has a symptom or abnormal lab finding it is imperative to answer the question “could it be the medication?”  An additional step is to check for drug interactions between all the medications a patient takes — easy on a smart phone or computer.

Prescribers may recall the side effects that were listed when a drug first went on the market — but quietly pharmaceutical companies discover more side effects which are later added to the product literature in fine print.

Here are some real life examples:

  • A patient who takes several blood pressure medications is hospitalized with another episode of abdominal pain due to pancreatitis.  $10,000 worth of tests find no cause.  The patient is sent home and told it must have been due to a gall stone that passed undetected.    WRONG — it was due to the side effects of the blood pressure medications.  Medications changed, problem solved.
  • A patient takes a new oral anticoagulant and needs a heart procedure.  The blood test shows a low platelet count.  $10,000 worth of tests give no clue.  A bone marrow biopsy is proposed.  WRONG –The patient finds an internet site shows the new drug may cause a low platelet count.  No bone marrow test is needed.  Medication changed, problem solved.
  • A patient gets sunburned easily and friends comment on a suntan even in the winter.  The medical diagnosis:  fair skin.  WRONG — the blood pressure medication causes photosensitivity.  Medication  changed, problem solved.

No matter whether the drug side effect is rare or common, if it happens to you it is 100%.   Pharmaceutical companies rate the frequency of certain side effects.  Indeed, this is helpful to health care providers — they figure out a diagnosis by mentally sifting through possibilities based on likelihood.   Right lower abdominal pain is most likely appendicitis but surgeons well know there are other causes.

From a patient standpoint sometimes it is enough just to know that a drug could possibly be the cause of symptoms.  If those symptoms start right after a drug was prescribed it does not take a rocket surgeon to figure out the problem.

Drug side effects are not behind every symptom.  Such thinking could be very dangerous.  To hesitate to see a doctor about chest pain because it could just be a drug side effect would be crazy.   Also, there are unavoidable side effects — you might not like the side effects of a medication but sometimes there is no alternative (like medications to prevent organ transplant rejection).

The proactive patient should always check for possible side effects of their medications and discuss the findings that match symptoms with a health care provider.   Just searching the drug name and “side effects”  almost always gets the list you need.  Another source is patient reported side effects.  Several web sites are available — this one is sometimes helpful eHealth.me

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