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Polypharmacy

Columnist: James DeVore, M.D.
July, 2016 Issue
Columnist

James DeVore, M.D.
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As a society, American patients are out of control with their appetite for more and more drugs.

Dale felt lousy. He couldn’t quite put his finger on it, but he was run down and complained of fatigue, achiness and an upset stomach. After weeks of feeling like this, Dale was “sick and tired of being sick and tired.” As he sat there in the exam room, he wanted answers. I’d done a thorough work up to try to pinpoint the problem, but nothing showed up.

I was pretty sure that his vague symptoms were drug-related side effects—not surprising, since Dale was on nine different medications. He was taking a blood thinner for his heart, two blood pressure drugs, a statin for his cholesterol, two different diabetes medicines, a drug for diabetic nerve pain, an acid blocker and a generic sleeping pill. It wasn’t hard to deduce he might be showing symptoms from one or perhaps a combination of medications. Was this a case of polypharmacy?

“Polypharmacy” is a term that describes taking multiple medications at the same time. This is a very big deal for millions of Americans, like Dale. The potential for drug-related side effects and drug-to-drug interactions increases dramatically with the number of medications. (The monthly out-of-pocket cost of these meds becomes ridiculous, too, but that’s another issue.) As a society, American patients are out of control with their appetite for more and more drugs, and doctors are out of control with their willingness to prescribe them. It’s estimated that more than 40 percent of people over 65 take six or more drugs daily. It’s not an exaggeration to say that if you go to the doctor with any symptom, there’s a pretty good chance you’ll leave with a prescription.

This is a huge concern. If you look at the information that’s provided by drug companies, you’ll find that virtually every drug has a laundry list of side effects. Reading this material can be frightening. Even common drugs that we all have in our medicine cabinets sound scary: Tylenol is toxic to your liver, Sudafed causes strokes and Claritin wreaks havoc on your kidneys. And those are just “safe” over-the-counter drugs. Wait until you get to the ones Dale’s taking. If he did even a cursory internet search, he’d surely be alarmed. Based on this reasoning, it seems crazy that Dale is taking all those meds. What are his doctors thinking?

The problem isn’t that simple. Dale, for example, has heart disease, hypertension, hyperlipidemia and diabetes. He’s seriously overweight and out of shape. His diet is loaded with starch, fat and way too much salt.

And there’s more: Dale wasn’t blessed with the healthiest genes. His father and multiple other relatives had early heart disease. Dale followed suit with a heart attack two years ago and now has stents propping open his blocked coronaries. His current combination of medications is the result of state-of-the-art, evidence-based guidelines for a person with heart disease, diabetes, hypertension and hyperlipidemia. In fact, there’s overwhelming scientific evidence that Dale’s medications will help control his sugar, blood pressure and cholesterol and, therefore, dramatically reduce his chance of further cardiovascular complications or death over the years to come. And therein lies the dilemma.

Any decision to take a medication should be weighed carefully. Every drug has risks and benefits; hopefully, the good is worth the bad. It’s really that simple. You probably make decisions like that regularly without even thinking about it. If you have a headache and decide to take an Advil, you’re risking an upset stomach to get the headache relief. If a man decides to take Viagra, he risks diarrhea, abnormal vision (your partner looks green) and fainting. None of those will boost your “manliness”!

Most people are more willing to take a drug that has a noticeable beneficial effect than drugs that have silent benefits. For example, pain pills or sleeping pills (or manliness meds for “ED”) have a benefit that can be directly experienced. But if you take a “statin” for your cholesterol or a blood pressure pill or a combination of diabetes drugs, you don’t actually feel any better. In those cases, you must believe that the long term benefits (reduction in cardiovascular risk or other complications) are worth the risks, chance of side effects and cost.

Back to Dale. He’s still sitting there in the exam room feeling lousy and looking for answers. What should we do? If you’ve read any of my previous columns, I suspect you might have an idea of how I’d approach this.

If you were the doctor what would you suggest?

 

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