June 28, 2016

"Are the Oldest Patients Getting Too Many Drugs?"

Seeing that headline on one of my daily MEDPAGE TODAY emails, I immediately clicked on the link to get the full story. I've been getting flack from family members, friends, and doctors over my decision to stop taking statins for cholesterol, and antihypertensives for my blood pressure.

The lead sentence of the story sparked even more interest:
​T​oo many healthy people in their 80s and older are being treated with statins and hypertensives for stroke prevention, according to British commentary in​ Evidence-Based Medicine.

Evidence-Based Medicine is a British​ medical journal. The article was authored by Kit Hyatt, a geriatric medicine physician at Hereford County Hospital in England.

In those who are old and frail, Hyatt wrote, the statins and hypertensives are "largely irrelevant" for preventing strokes:
The epidemiology suggests that, by this stage, hypertension is not an attributable risk factor for stroke and hypercholesterolemia has little effect on stroke risk overall. The largest trials of antihypertensive therapy and statins in this age group show at best a marginal clinical reduction in stroke and very modest clinical reductions in other cardiovascular endpoints.

And on top of the lack of substantial benefit, there is some evidence that morbidity associated with statin use is under-reported, Hyatt said.

The reactions of several U.S. cardiologists contacted by Med Page Today to Hyatt's perspective were mixed.

William O'Neill, M.D., at the Henry Ford Hospital, supported Hyatt's viewpoint:
I wholeheartedly agree with the author that we overprescribe medications in elderly asymptomatic elders. I never start patients in their 80s on statins for primary prevention. If they have not had a cardiac event by that age, it is unlikely that they will during their life. Antihypertensives can cause severe orthostatic hypotension and I am very conservative with these agents.

He also worried about the "polypharmacy that occurs with elders:"
I often see patients coming in with 15 to 20 different medications they are supposed to take. I honestly don't know how they keep the medicines straight. I tried to limit meds to three or four at most, and ideally at once a day dose.

Speaking on behalf of the American Heart Association, Daniel Lackland of the Medical University of South Carolina, commented that "elevated blood pressure is a stroke and cardiovascular disease risk factor at all ages, including the very old."

​Ken Uchinem M.D., at the Cleveland Clinic, said "We cannot assume that because the contribution of hypertension is smaller as one gets older, that treatment would not reduce stroke."

The American College of Cardiology and the American Heart Association do not make firm recommendations about the use of statins for patients older than 73, because there is inadequate data for older patients. Several clinicians emphasize the importance of individualizing treatment decisions in the older age group.

John Higgins, MD, MBA, of the University of Texas Health Science Center at Houston (UTHealth) made a comment that accords with my views on statins and hypertensives for the elderly:
While there are guidelines that aid in management, ultimately it is an individual decision between the physician and the patient, after weighing the risks and benefits of treatment as well as factoring in the patient's quality of life, other medical condition, risk for stroke and heart attack, and life expectancy.

Next month, I'll discuss how I've changed my own pill regimen and bucked the over-medication trend among seniors. Prescribed meds now? Only one. Supplements? Only three.

1 comment:

Linda Fernandez said...

Thanks for continuing to share your knowledge with all of us following closely behind you, John!