20 November 2012

The tablets that do more harm than good

GPs are increasingly prescribing older people a cocktail of drugs that they do not need.

The everyday practice of medicine may seem much the same as ever - diagnosing what is amiss and, hopefully, putting it right.

But recent years have witnessed a profound shift in the nature of the 'clinical encounter', in favour of doctors staring at their computer screens, filling in protocols, checking everyone's cholesterol level - and an almost indecent enthusiasm for prescribing drugs.

The number of prescriptions issued in Britain has risen threefold in just 15 years, and it's now quite common for those in their seventies and beyond to be taking half a dozen (often considerably more) different medications.

The impression of being almost coerced into taking increasing numbers of pills has been a recurring theme for hundreds of people over the past few years.  As one person said: 'I visited my surgery for a 'flu' jab in a positive state of mind and ended up a worried patient.' this was after the practice nurser seized the opportunity to suggest 'a few blood tests.'  Summoned back a week later, such patients can learn they have hypertension, diabetes or 'a 20% risk' of having a heart attack, warranting indefinite treatment.

Those who are otherwise fit and healthy are quick to spot the adverse effects of their wellbeing: 'Within a couple of weeks I went from being an active 65-year-old to a doddering old man,' says one.   'Would I be right in thinking the purpose of my joining the vast numbers of people taking unnecessary drugs is to boost the practice's income?' enquired a 'fit and healthy' 76-year-old.

This 'escalating polypharmacy', as it has become known, is undesirable for several reasons.  The burden of adhering to complex drug regimes, which can involve taking up to 20 pills a day in divided doses, significantly compromises the quality of people's lives, generating a morbid preoccupation with their ailments.

Needless to say, polypharmacy massively increases the risk of side-effects - a particular hazard for the elderly in whom every aspect of the metabolism and excretion of drugs may be impaired.  Hence the well-documented finding that 15% of acute hospital admissions in this age group are assocated with medication-induced problems, such as dizziness, falls, confusion and dehydration - four times greater than in younger patients.

This is futher ascerbated by what is known as the 'prescribing cascade', in which the side effects caused by one drug lead to another being added.  So, for example, cholesterol-lowering statins commonly induce muscular aches and pains, which are then treated with anti-inflammatory drugs that raise blood pressure, warranting treatment with anti-hypertensives.  And so on ...

Polypharmacy has cumulative consequences beyond the side effects of individual drugs.  It's responsible for a recognisable syndrome of tiredness, poor memory, depression and muscular aches and pains commonly, but wrongly, attributed to 'getting on in age'.

The quality of many people's lives is seriously compromised by a tidal wave of medication-induced (or iatrogenic) illness. The problem is that polypharmacy has become entrenched in everyday medical practice.  How, one might reasonably ask, did this situation arise, and why do doctors, in general, seem to reluctant to do anyting about it? 

Remuneration of Doctors for several years has been linked to their success in achieving certain targets.  The value of treating the minority of patients who have markedly raised blood pressure, cholesterol or blood sugar levels is indisputable in substantially reducing the risk of heart attacks and strokes, and controlling the symptoms of diabetes.  

So it was proposed that rather than just assuming, as in the past, that GPs would identify such patients and treat them appropriately, now they would have to demonstrate that they had done so - or be financially penalised with a reduction in their income.  Fair enough.
attractive 60 year old woman smiling at the camera Royalty Free Stock Photo
Does this woman look as though she needs to be put on statins?
But the requirement to adhere to the centrally imposed, bureaucratically determined targets can result in over-treatment. There has been a consistent tendency by various 'expert' bodies, such as the National Institute for health and Clinical Excellence (Nice), to expand by millions the numbers deemed eligible for medication.

This is done by consistently lowering the arbitrary cut-off point for initiating medication: hence in the various guidelines published in the past few years, where 'normal' cholesterol has been whittled down from 5.5 to 4 mmol/l, while the previous definition of diabetes (blood sugar greater than 7.9) has been reduced to 7.1.  Similarly with hypertension, where the previous starting point for automatic treatment, at 160/100, has been reduced to 140/90.

This incentive to over-treat is further compounded by reference to a 'cardiovascular risk' assessment formula, which is based on highly complex statistical calculations - according to which, treatment is advised for virtually everyone over the age of 60, even where blood pressure or cholesterol levels are normal or only slightly elevated.

Family doctors may rightly query, on commonsensical grounds, the clinical meaningfulness of these targets, or indeed be concerned at their potential for iatrogenic harm - but none the less are compelled, within their contractural arrangements, to adhere to them.

It's frequently reiterated that all those targets are 'evidence based' - that is, grounded in the findings of such well-publicised clinical trials as a recent paper from Oxford University researchers purporting to show that everyone over the age of 50 should be taking cholesterol-lowering statins.  These clinical trials are indeed massive, involving tens of thousands of participants - but because the benefits they seek to demonstrate are so small,, huge numbers are needed to show they exist at all.

And being very costly, they must be paid for and organised by drug companies - whose interpretation of their findings is inevitably coloured by the prospect of billions of pounds' revenue, generated by the mass prescription of those remedies whose efficacy they are intended to evaluate.

The family doctors' contract may have originated with good intentions but it has transmuted into a monster - distrating doctors' attention from responding to the complex needs of their patients in favour of the mass prescription of these drugs on which their income so closely depends.

A decade from now it will be seen as such, but in the meantime everyone can do themselves a favour by insisting that 'less is more' - the fewer drugs they are taking the better.

(From an article by James le Fanu)

Article in the paper today (Telegraph 21 Nov 12) says 

"Routine health checks for over-40s do more harm than good, doctors warn".

They say the approach does not help people live longer, but does result in unnecessary worry and treatment.  

The universal health check for the over-40s was introduced in 2009, under which scheme those between 40 and 74 are invited to their GP once every five years to have their blood pressure, weight and cholesterol levels checked, before being given advice about their way of life.

The hope is that people will eat more healthily and exercise more if they are told that they have a raised risk of heart disease, cutting death rates int he long term.  Those with pressing health problems will also be offered treatment sooner.

But there has been found to be no consistent evidence that these checks improved health or reduced death rates, neither overall nor for cardiovascular or cancer causes.

All medical interventions can lead to harm with the possible harms including over-treatment, distress or injury from invasive follow-up tests, distress due to false positive test 
results, false reassurance due to false negative test results.
Those who turned up for health checks tended to be better off and healthier, or the 'worried well', thus systematic health checks may not reach those who need prevention the most.  

Having read the above article, which makes a great deal of sense, there is ather factor to consider which is that these tests have only been running since 2009.  We are more likely to make a difference in the very long term, not over a short three years.

As the old joke says:
  • Patient: Doctor, obesity runs in our family.
  • Doctor: The problem is that no-one runs in your family!

Another view: http://iaindale.blogspot.co.uk/2006/01/exclusive-proof-that-patricia-hewitt.html

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