Ten Drugs Doctors Should Consider De-Prescribing
Full credit to Dr David Edelberg for this post.
Physicians use the word polypharmacy when a patient is taking five or more prescription drugs daily. A recent survey showed that half of women Medicare recipients were taking five or more drugs daily, and 12% of them were taking ten (!) or more.
New patients frequently arrive at WholeHealth Chicago carrying bags stuffed like piñatas with prescription drugs and nutritional supplements, the latter recommended by someone (online ad, health food store clerk) and never discontinued.
The online medical journal Medscape recently published a list of drugs doctors should strongly consider discontinuing in their patients. My first thought? “It’s about time.”
Here’s the list:
Antibiotics before dental procedures to prevent infection are frequently but misguidedly recommended. Both the ADA (American Dental Association) and the AAOS (American Academy of Orthopedic Surgeons) no longer encourage prophylactic antibiotics because there’s no evidence that doing so prevents much of anything.
Proton pump inhibitors (PPIs including Prilosec, Prevacid, Protonix, Dexilant) for long-term use. There are a handful of patients who do need daily PPIs–mainly those with severe reflux and elderly patients taking NSAIDs–but most do not. PPIs interfere with the absorption of calcium (increasing fracture risk), vitamin B-12, and thyroid and increase the risk of C. difficile infection.
Statins for the primary prevention of heart disease. Here’s the title of one JAMA article that says it all: The Debate is Intense But the Data Are Weak. Statins are statistically useful in reducing heart risk in people with diabetes as well as preventing a second heart attack in someone who has already had one. But doctors are prescribing statins less frequently for people who have high cholesterol but no other risk factors. It’s also being recommended that statins not be prescribed to anyone over 75.
The “Z drugs” after age 65 need to be prescribed with care. These include the anti-anxiety benzodiazepine and the sleep meds zolpidem (Ambien), zaleplon (Sonata), temazepam (Restoril), and eszopiclone (Lunesta), as well as the numerous SSRI antidepressants. All are associated with mental confusion and increased falls with fractures.
Beta blockers (atenolol, propranolol, sotalol, etc.) were once high on the list for people who had had a heart attack, to improve what’s called long-term mortality, but recent research has not sustained this. For years beta blockers were a go-to med for high blood pressure, but again, they’re just not all that great compared to other meds available. Because the side effects outweigh the benefits, we’ll see fewer of these being prescribed.
Medications for asthma and chronic obstructive lung disease. Some people need inhalers, especially so-called rescue inhalers, during allergy season. But, interestingly, a recent study showed that among patients prescribed long-acting inhalers like Advair and Symbicort, many never had a confirmed diagnosis of asthma. The current recommendation is if a doctor suspects a patient has asthma, ensure the diagnosis is accurate by using spirometry testing (or a referral to a pulmonologist) before prescribing a lifetime of expensive inhalers.
Medications for urinary incontinence caused by bladder spasm (overactive bladder), including Vesicare, Ditropan, and Flomax, are effective for maybe 10% of patients and are discontinued because of side effects in 7%. They’re generally useless for everyone else.
The most commonly prescribed medication for Alzheimer’s, Aricept (donepezil), usually works for only one patient out of ten and in that instance for a relatively short time. Side effects are very common: nausea, lack of appetite, urinary incontinence, weight loss, and fainting.
Muscle relaxants for back pain (methocarbamol/Robaxin, cyclobenzaprine/Flexeril, carisprodol/Soma, and a dozen others) generally don’t work and cause side effects in most people (drowsiness, dry mouth). In my practice, I used to prescribe low doses of a time-release (once a day) version of cyclobenzaprine called Amrix, which is often effective for people with fibromyalgia. But the Big Pharma company that makes it knew it had an effective drug, got greedy, and bumped up the price to $1,100 for 30 capsules. Insurers are simply refusing to pay for it.