Drug-Drug Interactions Put Elderly at Risk

Barry called me when he read thisarticle in MedPage Today. Why don't people understand the problems polypharmacy cause and especially when they don't talk to their doctors about all the dietary supplements and complementary and alternative medicines (CAM) they are taking? Barry said he talks about all medications he is taking and if the doctor ignores him, he asks the doctor why.

I commented that many people do not because in the past many doctors would tell their patients not to take non-prescription medications and were none too polite about telling them this. Other doctors would belittle them for taking CAM.

Barry agreed and said that these people are putting their lives in jeopardy. He said his friend that ignored the pharmacist and died a few days later was a huge wake-up call for him. I added that many people today are not concerned and feel that the doctors don't care or they would be asking the proper questions. Some people have been told by the homeopathic practitioners that the medications they order are natural and not to talk to medical doctors about them. This is because of medical doctors in the past talked against homeopathic medications and CAM.

I found this very much on point and a warning to our doctors!

Action Points

• One in six U.S. seniors might be potentially at risk for a major drug-drug interaction, and 25% of adults did not disclose herb or supplement use to primary care physicians.
• Note that one study found that one-third of the population used complementary and alternative medicine.

Based on the 20 most commonly used medications and the 20 most commonly used supplements, the researchers identified 93 potential drug-drug interactions. And among the 20 common medications, 15 interactions were classified as "potentially of major or life-threatening severity."

Much of the article was about the following and I find this interesting and conflicting at the same time as many doctors do ask for a complete list or bringing in all medications to their appointment. The most common reason for nondisclosure was lack of inquiry by physicians (57%), while 47% of patients said they didn't believe their physician needed to know about their use of CAM.

"Contrary to earlier findings, our results attribute most nondisclosure to physicians not asking about CAM use or to concerns about physician knowledge regarding CAM rather than to physician discouragement or negativity about the use of CAM," Jou and Johnson wrote.

Only 2% of patients said their physician had discouraged them from CAM use in the past, and 3% said they had received discouragement in the present.

"Physicians should consider more actively inquiring about patients' use of CAM, especially for modalities likely to be medically relevant," they wrote.

Are People with Diabetes Taking Too Many Supplements?

This is one of the better blogs by a CDE and deserves readership by people with diabetes even though it is written for CDEs on the AADE website. Carla Cox is right that there has been resurgence in advertising for herbal and other supplements. Late night TV has many advertisements for drugs that are supposed to help people with diabetes get off diabetes medications and others to help with weight loss.

The National Center for Complementary and Alternative Medicine says that nearly 40 percent of Americans use health care methods that are not considered mainstream medicine. The website for the National Center for Complementary and Alternative Medicine is here. Over half of the people with diabetes reportedly take nutritional supplements. Of these people, persons with type 2 are twice as likely and those with type 1 to use nutritional supplements.

In reading on diabetes forums, I often see alpha lipoic acid, cinnamon, chromium, ginkgo biloba, and a few others mentioned for various other maladies. The biggest problem for Complementary and Alternative Medicine (CAM) Supplement use that Ms. Cox is concerned about is the lack of double-blinded randomized control trails for most of the supplements.

One source is American Diabetes Association Guide to Herbs and Nutritional Supplements: What You Need to Know from Aloe to Zinc. This book is available through most bookstores and many libraries.

I do appreciate that Ms. Cox made the following statement. “It’s important to recognize that all products that change the way our body works are drugs, whether they come from “natural” or synthetic sources.” It is a problem that herbal products and supplements lack production and marketing oversight and then must be proven to cause serious health problems before they can be removed from the market.

Ms. Cox concluded her blog with a statement to ask the patients which supplements they are taking and why. Then she instructs CDEs to assess whether the supplements are healthful, harmful, or just costing patients extra money they may ill afford.

This was not available when the blog was written, but the FDA has declared one problem people with diabetes have, inflammation, a disease. This will open the door for Big Pharma to manufacture drugs for inflammation and prevent CAM from dominating in this area. I know that Big Pharma is pushing the FDA to do this in more areas as well.

Does Your Doctor Care If You CAM?

Maybe your doctor will not care if you are using complementary and alternative medicine (CAM), but you should. Not informing your doctor can cause health threatening and even life threatening situations if you keep this a secret. There are too many cases of patients saying that these medications are natural and therefore my doctor has no need to know, and they end up in the hospital or dead. Family members then are left to wonder what happened. Of course, they will blame the doctor, but this is when an autopsy can uncover the real cause.

If patients and doctors both used communication, most of these problems could be avoided and everyone could be in a better state of health. Many times doctors will just sarcastically dismiss CAM or tell the patient not to be taking vitamins, herbal medications, or homeopathic products. It is the wise doctor that will take the name of the medication and look them up and maybe learn something, but most doctors are against CAM because they were not taught about it in medical school and therefore it holds no value.

I am surprised by this doctor actually blogging about her experience, but this must be an above average (and I mean way above the norm) doctor. Claire McCarthy, MD is a primary care physician and the medical director of Boston Children’s Hospital’s Martha Eliot Health Center.

She states that in a study, researchers in Canada found that 64.5 percent of children were using some form of CAM, but more than a third did not tell their doctor. She also says that in the general population about 75 percent of patients using CAM don't make this known to their doctors. She cites three reasons for this secrecy – patients are afraid their doctors won't be happy; patients don't think their doctor needs to know, and the doctor did not ask.

I agree with her assessment that safety should always be first and foremost. Doctors will not know whether they are being safe in prescribing a medication without knowing everything the patient is taking. Medications can have interactions and not always good interactions. Therefore, it is imperative that patients communicate all medications and CAM being taken. Not all CAM physicians are cautious when giving out herbal and homeopathic medicines and can cause adverse drug interactions unintentionally.

Dr. McCarthy states, “We doctors have a strong (and understandable) tendency to think within our own traditional medicine worlds. But, there is a much bigger world than traditional medicine when it comes to making patients feel and get better. And sometimes it’s patients who need to teach doctors.” This is a doctor that has her patient’s safety where it should be – first.

In her blog, she even lists the National Center for Complementary and Alternative Medicine (NCCAM) so that people can explore the site. She blogs here and here and is interesting to read for parents with small children.

Communication About Alternative Medications Lacking

This subject just won't go away. And I can understand why. Too many people feel that the doctors and other medical occupations, including pharmacists have no reason to know about what natural remedies they use. Complementary and alternative medicine (CAM) is prevalent in most countries and under reported by patients.

This is dangerous because some can have deadly effects when taken with prescribed medications. While this was a survey, it still indicates the people over the age of 50 often do not inform their healthcare providers of the CAM supplements they are taking. One question apparently not asked is whether they are doing this on their own or from recommendation of homeopaths. Either way, many are putting themselves at risk of fatal combinations of medications.

CAM is a diverse group of medical and healthcare interventions, practices, products, plus disciplines that are not generally part of conventional medicine. While older Americans wish to lead healthy and active lives, the CAM, which includes herbal supplements, manual therapies, and mind/body practices such as chiropractic care, massage, acupuncture, and meditation are sometimes counter productive with medical interventions.

Mainly it is the herbal supplements, but any of them can cause problems depending on the medical treatment a patient is receiving. I do use chiropractic care, but there have been times the chiropractic doctor has wisely refused treatments as they would have interfered with the medical treatment I was receiving. So communication is important with all concerned, not only to prevent problems, but for your own medical safety.

CAM can be an important factor in staying healthy, but care needs to be taken as some CAM products will make certain conventional medications less effective and lead to potentially deadly interactions. Patients need to communicate with their doctors and vice versa.

The AARP/NCCAM survey also found that it was the patients that brought up the topic of CAM most frequently. The two main reasons respondents gave for not discussing it was that the doctor never asked (42 percent) and the patients did not know they should bring it up (30 percent).

AARP is the American Association of Retired Persons which I do not belong to for personal reasons, and NCCAM is the National Center for Complementary and Alternative Medicine.

The article about the study can be read here.