Are You Taking Too Many Pills?

Normally, I would not take a topic from the NY Times. However, since this is one of the better articles on polypharmacy, and covers the topic quite well, I will use it.

About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

The above statement is very powerful, but most hospital administrators care less as long as they make their bonus. Many hospitalists send patients home on the same or more pills than they prescribed for them while in the hospital.

The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But, older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

Some drugs are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.

Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it could reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

The above paragraph shows the problems that doctors have and the possible influence of Big Pharma on their prescribing habits. Unfortunately the following paragraph is also true and adds to the problems.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.

Frailty a Risk of Polypharmacy

Polypharmacy is a problem for many of the elderly. As we age, many people often develop more chronic health conditions. These chronic health conditions mean that the elderly often are taking many medications. This means polypharmacy for many of the elderly and it can increase the risk for harmful side effects.

Interestingly, taking more than five medications is linked to frailty; perhaps because the medications interact to affect our ability to function well as we age. Frailty is a problem associated with aging. Someone who is frail can be weak, have less endurance, and be less able to function well. Frailty increases the risk for falls, disability, and even death.

Recently, a team of researchers examined information from a large German study of older adults called ESTHER (Epidemiological Study on Chances for Prevention, Early Detection, and Optimized Therapy of Chronic Diseases at Old Age) to learn how taking more than five medicines might affect frailty in older adults. The study was published in the Journal of the American Geriatrics Society.

The researchers looked at information from nearly 2,000 participants in the ESTHER study, which began in 2000 with nearly 10,000 participants. Follow-ups on participants were conducted after two, five, eight, and 11 years. People in the study were between 50- and 75-years-old when the study began.

At the eight-year follow-up, study physicians visited the participants at home for a geriatric assessment. During the visit, participants were asked to bring all the medications they took--both prescription and over-the-counter (OTC)--to assess the kinds and number of medications participants were taking. The researchers then separated participants into three groups:

1. People who took from 0 to 4 medicines (non-polypharmacy)

2. People who took 5 to 9 medicines (polypharmacy)

3. People who took 10 or more medicines (hyper-polypharmacy)

Two pharmacists individually reviewed all medications taken and excluded medicines and supplements that were not known to cause side effects.

After adjusting for differences in patient characteristics including illnesses, the researchers learned that people who were at risk for frailty, as well as people who were frail, were more likely to be in the polypharmacy or hyper-polypharmacy groups compared with people who were not frail. Researchers also discovered that people who took between 5 to 9 medicines were 1.5 times more likely to become frail within 3 years compared with people who took fewer than 5 medications.

People who took more than 10 medicines were twice as likely to become frail within three years as people who took less than five.

The researchers concluded that reducing multiple avoidable prescriptions for older adults could be a promising approach for lessening the risks for frailty.

If you're an older adult, or if you're caring someone who is older, it's important to understand that taking multiple medicines can cause interactions. The medicines can interact with each other and with the human body in harmful ways (by increasing negative side effects or decreasing desired effects, for example). As a result, the risk for falls, delirium, and frailty also increases.

Primary care providers are aware of these negative effects, but they cannot properly react if they are not fully informed about all the medicines you or an older adult in your care may be using. That's why it's extremely important to let your healthcare provider know about all medicines you or a person in your care is taking, as well as about OTC medicines and medicines prescribed by other healthcare providers. Your can then evaluate whether one or more drugs might be changed or discontinued.

"In a perfect world, your physician would talk about your medications with a pharmacist and a geriatrician. This might help to reduce avoidable multiple drug prescriptions and possibly lessen medication-induced risks for frailty and other negative effects of unnecessary, avoidable polypharmacy," said study co-author Kai-Uwe Saum, PhD, MPH.

This research summary was developed as a public education tool by the Health in Aging Foundation. The Foundation is a national non-profit established in 1999 by the American Geriatrics Society to bring the knowledge and expertise of geriatrics healthcare professionals to the public. We are committed to ensuring that people are empowered to advocate for high-quality care by providing them with trustworthy information and reliable resources. Last year, we reached nearly 1 million people with our resources through HealthinAging.org. We also help nurture current and future geriatrics leaders by supporting opportunities to attend educational events and increase exposure to principles of excellence on caring for older adults. For more information or to support the Foundation's work, visit http://www.HealthinAgingFoundation.org.

More on Polypharmacy

I had expected one or two emails after writing this blog on the unbelievable pile of pills, but I am now over a dozen emails. Many had parents that they had checked on and were surprised at the number of potential deadly medication conflicts in their possession. Two of the emails said they needed to take a parent to the pharmacist to prove to them the danger they were going to have. Another three could not believe even themselves what their parent was doing on statins and the amount of grapefruit the parent(s) were eating. One needed to take a parent to the hospital because of this.

Most of the parents would not believe the son or daughter because the vitamins, minerals, and grapefruit are considered natural. This required accompanying the parent to a doctor appointment and even then, the parent would not believe the doctor. How could something natural conflict with a prescription medication? Heart medications and statins were the two most problematic medications.

Other problems discovered were many pharmacies being used to prevent discovery of opioid use. This was a real surprise for a couple of children. One son was told to get out their house and never come back. Several phone calls were needed to notify the emergency room, two doctors and several pharmacies to let them know of the parent's addiction.

This is the reason I blog and will continue to blog about polypharmacy and other problems that people with diabetes can face. Polypharmacy has scared me the most and in talking this over with my pharmacist, she stated that this is more common than many people even want to know. She said she tells people quite often that the vitamins, minerals, and over the counter drugs will cause problems with the prescription they have just filled, yet they ignore what she says.

I told her that I still remember what she told one individual that ignored her and ended up dead two days later. I said I have known others that come in here to fill one prescription and travel to another town to fill another prescription of opioids. She said that the state is starting to step up prescription checks on opioid prescriptions and she now has several that she gets alerts on to not fill prescriptions.

She then asked about the Gabapentin that I have filled about every 90 days. I said that I have been moved up and down in my dosage and that two per day were for the neuropathy pain and one was for a muscle pain until that cleared up and now the third one is for arthritis pain in the lower spine. I said that the neuropathy pain was only blunted somewhat, but that I did not want a stronger pain medication until it became worse. The arthritis pain was more of an aggravation and only really bothered me when I was doing a lot of bending over.

She said good as there were several more levels of medication that would help if the pain became worse. I said I know and Lyrica would be one of them for the neuropathy, but I don't want that until I need it. She said it could help, but if I didn't want it, that was good. I said I don't know everything about the arthritis yet, but I hope that I don't need anything more for quite a while. With that she had a customer she needed to help and I left.

Polypharmacy, the Unbelievable Pile of Pills!

With the baby boom generation now on social security, polypharmacy is becoming rampant. Those of us with diabetes already have problems with polypharmacy. Moreover, I am not limiting this to prescription drugs. Herbal medications and over-the-counter drugs also count. Yet, many people ignore herbal drugs, vitamins, and minerals because they are supposedly natural.

Geriatricians and researchers have warned for years about the potential hazards of polypharmacy, usually defined as taking five or more drugs concurrently. Yet, it continues to rise in all age groups, reaching disturbingly high levels among older adults.

Doctors spend an awful lot of money and effort trying to figure out when to start medications, and shockingly little on when to stop. Most keep adding medications and never stop.

The average senior is now taking more medicines than ever before. Many are for complex conditions or diseases, and others are for what they think will help them remain healthier.

Tracking prescription drug use from 1999 to 2012 through a large national survey, Harvard researchers reported in November that 39 percent of those over age 65 now use five or more medications — a 70 percent increase in polypharmacy over 12 years.

Many factors probably contributed, including the introduction of Medicare Part D drug coverage in 2006 and treatment guidelines that (controversially) call for greater use of statins.

Nevertheless, older people don’t take just prescription drugs. An article published in JAMA Internal Medicine, using a longitudinal national survey of people 62 to 85, may have revealed the fuller picture.

More than a third were taking at least five prescription medications, and almost two-thirds were using dietary supplements, including herbs and vitamins. Nearly 40 percent took over-the-counter drugs.

Not all are imperiled by polypharmacy, of course. But, some of those products, even those that sound natural and are available at health food stores, interact with others and can cause dangerous side effects.

How often does that happen? The researchers, analyzing the drugs and supplements taken, calculated that more than 8 percent of older adults in 2005 and 2006 were at risk for a major drug interaction. Five years later, the proportion exceeded 15 percent.

All of this points out how dangerously the older generations are living and possibly causing their own death because they have concealed information from doctors or use too many doctors to hide what they are taking. Many also use several pharmacies.

While I am a senior, I would urge all my readers to read the full article about polypharmacy and if you have a parent still alive, you need to check out the drugs in their possession. If necessary make a list of the drugs being used and the frequency being used, the pharmacy used and then talking to at least one pharmacist using this list. Take action if anything is found that could be dangerous for the elderly parent.

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.

Seven Neglected Areas That Sabotage Healthy Aging – P8

When is comes to the elderly, too many have polypharmacy, me included. Diabetes also adds to the medications. In the elderly, the problem can become severe because of the risk of harm from medication side effects. The CDC states that every year, 177,000 older adults visit the emergency room for medication problems. This is not a great thing to happen to the elderly and it is unknown how many deaths happen because people cannot reach the emergency room.

Polypharmacy is often a burden for the elderly because of the cost of medications. Often a decision needs to be made between medications and food and a medication prescription is not filled as a result. In addition, real hassles occur for many of the elderly in timely taking their medications during the day, especially if they have too many medications. This often can make a chronic condition become worse and lead to doctors failing to realize that the patient has not been able to take all medications as directed.

The point to remember for many of the elderly is that doctors are taught to prescribe medications and often it may be a case that some medications need deprescribing. Research has documented that inappropriate prescribing of medications is common. A careful medication review will often identify medications that are marginally useful or no longer necessary, but you may not get such a review unless you request it.

For more information:

• How to Review Medications for Safety & Appropriateness
• How to Think Like a Geriatrician about Senior Medications
• A Prescription for Confusion: When to Take All Those Pills
• MedStopper.com (Pharmacist-created online resource designed to help with deprescribing)

My blogs:

http://bobsdiabetes.blogspot.com/2014/03/is-polypharmacy-in-your-future.html

http://bobsdiabetes.blogspot.com/2014/04/more-about-my-friend-on-polypharmacy.html

http://bobsdiabetes.blogspot.com/2014/04/polypharmacy-how-i-dislike-you.html

http://bobsdiabetes.blogspot.com/2015/04/polypharmacy-and-diabetes-part-1.html

http://bobsdiabetes.blogspot.com/2015/04/polypharmacy-and-diabetes-part-2.html

http://bobsdiabetes.blogspot.com/2015/10/even-doctors-complain-about-polypharmacy.html

Number 8 of 8 blogs.

Even Doctors Complain about Polypharmacy

I suggest that you read this blog by Val Jones, MD. She tells the story of polypharmacy better than I can. The points she raises include:

• Patients are notorious for non-adherence
• Policy wonks say that more than half of patients do not take their medications as directed
• Missed opportunities to control chronic illnesses cost us billions of dollars and millions of quality life years annually

The reverse is just as serious:

• The costs of polypharmacy (over medication) is not known or discussed
• The unwanted side effects and medication interactions (both known and unknown) can be devastating
• An astonishing number of these incidents (falls and injury accidents) are related to drug side effects

Important factors to consider:

• There are costs to not taking medicines
• There are costs to taking medicines
• It is unknown how many injuries are accidentally prevented by patient non-adherence

This doctor considers it a victory each time she reduces the number of medications her patients use. What I like about this is she is not a geriatrician, but thinks like one. You should read her blogs on her website here.

Polypharmacy and Diabetes – Part 2

In the previous blog I used the following - other definitions have appeared in the medical literature that put the problem of polypharmacy in a broader perspective. One defines polypharmacy as the “prescription, administration, or use of more medications than are clinically indicated, or when a medical regimen includes at least one unnecessary medication.

I had wanted to say then that often the elderly are prescribed a statin because of slightly elevated cholesterol. Yet the doctors seldom do a benefits analysis to determine if it might be better to withhold statins. These doctors would rather prescribe statins which dramatically increase the risk of type 2 diabetes. I know this because I have a friend that was prescribed a statin at the age of 88 that did not have diabetes. Last month (at age 89) he was diagnosed with type 2 diabetes and Allen and I have been working with him to help him manage his diabetes. And I have personal experience because the doctor rushed to prescribe a statin for my wife about 22 months ago and now she has type 2 diabetes.

Another problem all of us face today is the direct-to-consumer advertising. It is blasted at us daily and a few of the side-effects which may be mild are rushed through and not actually spelled out. The medications are hyped as the latest and greatest. Then many patients and their families demand the medication. Even more problematic is that they then ignore warnings about why the drug may not be in the best interest if the patient.

The lay media frequently report outcomes of clinical trials, often before complete reports are available to physicians through the medical literature. Brief reports in the press may give false hopes or heightened expectations for the benefits of new therapies without adequate explanation of their inherent risks. This drives demand from patients or their families for additional treatment.

Multiple medications creates problems unknown in medicine and is often underestimated by the medical profession. By increasing the number of medications, doctors increase the risk of adverse reactions – remember in the elderly there is no research to say they are safe. The aging process, other chronic illnesses or diseases, and polypharmacy places the elderly at increased risk of adverse reactions.

Now with this in mind, polypharmacy has additional problems, including but not limited to:

• Risk of duplication of therapy (multiple agents in the same class and generic and brand name versions of the same medications)
• Risk of patients seeing multiple prescribers and no one conducting oversight of the drug regimen (read my blog on this here)

Medication adherence among patients with chronic conditions is disappointingly low according to doctors. Doctors seem inclined to overestimate the degree of medication adherence. Adherence rates are diminished by:

1. Complex drug regimens
2. Incomplete explanation of drug benefits and side effects
3. Lack of recognition of a patient's lifestyle
4. Cost of medications
5. Communication style with the patient
6. Avoidance of including the patient in the decision

Adherence to a course of therapy is more positive when a patient understands the reasons for taking a medication and is involved in the decision to prescribe. Patients are more likely to have confidence in the prescriber if they are given basic knowledge of potential adverse effects and advice about what to do if such effects occur. Increasingly, clinical practice guidelines are incorporating quality of life and patient preferences to increase adherence by both physicians and patients. Finally, when doctors suggest generics instead of the more expensive brand name drugs. Read my blog on what doctors are saying about patients being noncompliant.

Review of a patient's drug therapy should begin with assessing the patient's adherence, asking about problems with side effects, and determining whether the provider's drug list in the patient's record matches the patient's own drug list. Asking patients to bring all of their medication containers to routinely scheduled office visits can facilitate this effort. Doctors can also help patients recall the need for each of their medications by adding the purpose to the directions for use in their written prescriptions (i.e., “once daily for blood pressure” or “two times a day and take with meal for diabetes”).

The medication list should include all prescription medications, including those taken routinely and those used on an as-needed basis; over-the-counter medications; herbal products; and vitamins or nutritional supplements. Medication lists constructed from memory or even from written lists are notoriously misleading and incomplete compared to examination of the actual medication containers.

Polypharmacy and Diabetes – Part 1

Again, I am listing a few of my prior blogs on polypharmacy rather than rewrite them. I find this a very interesting topic and one that I am fighting at the same time, as I take more medications than I like.

http://bobsdiabetes.blogspot.com/2014/03/is-polypharmacy-in-your-future.html

http://bobsdiabetes.blogspot.com/2014/04/more-about-my-friend-on-polypharmacy.html

http://bobsdiabetes.blogspot.com/2014/04/polypharmacy-how-i-dislike-you.html

Polypharmacy is the shame of our doctors, the FDA, and Big Pharma. Polypharmacy is a problem all people, but especially for those of us with diabetes. Problems inherent in polypharmacy include:

• Half of the people with type 2 diabetes are over the age of 65
• No research is done to determine how diabetes medications affect the elderly
• Doctors stack oral medications on the elderly with no research verifying that they will benefit them
• Doctors then complain about the elderly and others of not taking their medications
• No research has been done to determine how other medications prescribed will affect diabetes medications
• Many of the elderly are over medicated excessively.

There is basically no research done on the elderly (for any medication) to determine if the medications prescribed will perform as intended or if the elderly will get the benefit.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, pharmacy, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

Polypharmacy is a risk factor in the treatment of type 2 diabetes. In normal use, polypharmacy means the concurrent use of multiple medications in the same patient. What is forgotten in most definitions is the potential for harm that polypharmacy may pose for the individual. Other definitions have appeared in the medical literature that put the problem of polypharmacy in a broader perspective. One defines polypharmacy as the “prescription, administration, or use of more medications than are clinically indicated, or when a medical regimen includes at least one unnecessary medication.

Having written the above, I will admit that polypharmacy may be unavoidable. This is because multiple drug therapy has become a standard of care in most chronic conditions. The comorbidities of diabetes commonly include hypertension (blood pressure), dyslipidemia (cholesterol), depression, and coagulopathies (any disorder of blood coagulation), each of which may require one or more drugs for adequate control. Then add to this other conditions that often accompany diabetes, such as hypothyroidism, heart failure, and osteoporosis, and the total number of possible medications needed becomes significant. Lastly, the fear that doctors have about hypoglycemia, and they add oral diabetes medications on top of oral diabetes medication, up to four different medications.

As people age, the chance for other chronic conditions increases. With the availability of multiple medications and the variety of “expert” guidelines for the treatment of these conditions, additional drug therapy is often indicated. Debate has emerged about how many conditions need to be treated.

The burden of polypharmacy falls especially hard on the elderly, who incur the highest incidence of chronic conditions coupled with reduced or fixed incomes and therefore inability to afford the cost of multiple medications. Treatment of elderly patients with diabetes requires special considerations, especially in how aggressively diabetes should be treated. Treatment decisions should consider age and life expectancy, comorbid conditions, cognitive status, living arrangements, and severity of vascular conditions.

The variety of “expert” panel recommendations, clinical practice guidelines, and other national standards for medical treatment has grown exponentially in the last decade. The National Guideline Clearinghouse listed greater than 1,650 active clinical practice guidelines in July 2005, 386 of which were devoted to diabetes alone. Many of these guidelines overlap, and sometimes they contradict each another.

Clinical practice guidelines rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time. Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines.

The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “experts” could care less about treating the elderly.

Polypharmacy – How I Dislike You

You just can't make some doctors happy. Even though the doctor was smiling when he said I was a drug addict, I still took offense to the statement. Having had a doctor attempt to increase my dosage for several medications to bring me in line with the guidelines for recommendations for blood pressure medications and statins has left me with a sour taste in doctors. Add to this a great discussion with a VA doctor about eliminating one medication and reducing the dosage on another medication, I really can't understand why doctors are pushing to increase some medications so enthusiastically.

Admittedly, I would like to be off a few medications, but because of the lab reports and other tests, I know that I am where I should be for the results I am obtaining. I am lower than the guidelines for blood pressure readings, yet I have had to refuse to let the nurses take my blood pressure readings immediately after entering the exam room. Not only have they increased the pace from the waiting room to the exam room, but also taking the BP with the incorrect BP cuff is another trick they have used to bring my BP readings up.

Even my wife, who is a certified nurse aide, has the right cuff for me and my BP readings are consistently 115 to 125 over 60 to 75. Yet the doctors' nurses work to get my BP up to 140 (or higher) over 90 (or higher) so that the doctor will prescribe a higher dose of BP medication.

Now the cholesterol (lipid) panel seems to be all over the range. The latest test done at the VA showed everything within the normal range, but with a three day difference in blood draw, all my results done by the hospital lab were beyond the high limit of the range. I therefore have to wonder if the hospital lab reports are inflated for the doctors to enable them to increase the statin dosage. To check the hospital lab reports, on the same day, I went to the local hospital and paid out of my own pocket to have them do a blood draw and do a lipid panel. All the results were within the ranges and the ranges were the same as the VA and the regular hospital lab. All three blood draws were fasting and that is the reason I say that the results for the doctor were inflated.

I am beginning to think I need seriously to consider changing doctors and hospital labs. Not only would I save on distance traveled, but I may also save on frustrations. When it comes to my diabetes, I don't like the idea of leaving the endocrinologist I have, but I am tired of having the suggestion of letting my A1c get above 7.0 at every appointment.

Yes, they tell me that is because of my age that they make this suggestion. I tell them that until I am unable to prevent hypoglycemia, except for the rare episode, I will continue to manage my diabetes to the best of my abilities. Only three readings below 60 mg/dl in the last year and two were at times I suspected I would go low because of injecting the Novolog too close to the Lantus injection site and testing proved I was going low and the glucose tablets did their work. The lowest reading each time was 56 mg/dl and 58 mg/dl. I consider these low, but not severe lows. The third time I injected Novolog when I should have injected Lantus.

Now am concerned because I do not have the symptoms when I get below 70 mg/dl of sweating, being shaky, or the other symptoms. I seem to have become hypoglycemia unaware in the last year and that does concern me. As a person with type 2 diabetes on insulin, I always believed that only people with type 1 diabetes had this problem. This confirms that the analogue insulins can cause this condition in both types.

Is Polypharmacy In Your Future?

What is polypharmacy? There are several definitions so this is not always the best term to use.

1. The use of two or more drugs together, usually to treat a single condition or disease.

2. The use of a number of different drugs, possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several health problems.

3. The administration of many drugs at the same time.

Don't forget that the term drugs also includes herbal remedies, vitamins, minerals, and other supplements. Often they are referred to as dietary supplements, but they are still drugs. 

 

Normally this is a concern of the elderly. However, last Friday, I was in the house of a friend as he was sitting down for the evening meal. His wife was at the side table with her back to us. I could not be sure what she was doing until she seated herself at the table. She had one container for herself and a slightly larger one for her husband, each containing many pills.

Both are in their early 40's and I thought to myself, they are too young to be taking this many medications. Sure, I take 9 pills at breakfast and the same at bedtime and then insulin injections of two types. However, I am about 30 years their senior.

After they had finished eating, he and I headed for his workshop. Once there, I asked how many pills he took in a day. He said they were not all medications and that only eight were prescription. He said the rest are dietary supplements. I asked if any of them were prescribed and he said only one – vitamin D.

I helped him figure out the woodworking project he was making and gave him alternatives for making it stronger. We continued talking until he was satisfied and drawing different diagrams for the needed joinery. Then we went inside to his computer where I showed him where I had gotten my ideas and he looked at the explanations for several and bookmarked the page.

Next, I asked if he would read something that I had written about vitamin D. He moved over so I could access the keyboard and mouse. First, I brought up this blog and after he had read it, he called his wife and asked her to read it. Her first question was why the doctor needed to prescribe it if there was something less expensive. She went to the cabinet and brought the bottle over. She said this is definitely D2.

Now she wanted more information and went to her computer. I brought up the blog for her and when she went to the bottom and clicked on the University of Oregon link, she asked where to go. I told her to click on vitamins and she said they have something on all of these. More of a question, but she went to one other and was reading that. She bookmarked that and went to back to find the minerals. Then she asked her husband if he has been tested for selenium and he said no.

Now she said they had better do some reading and check out the rest that they were taking. I suggested that they also read the problems or cautions for use with prescriptions. She said that was what she was concerned about. She asked if I had any other suggestions and I gave her this blog, which she quickly bookmarked.

Then she asked for my email address saying she would probably have more questions. She sent me an email with her and her husband's email so that I would have them. Then she took time to read some of the other information on my blog page and asked if that was why I blogged. I admitted that because of diabetes and felt that it was important to pass on information to others.

Then I was shocked when she said she had just been diagnosed with type 2 diabetes the day before. I asked her if she had gestational diabetes with their two children and she said only the second one. She continued that the doctor had not believed her plasma blood glucose level and did an A1c and even then would not say she had diabetes. Next, she went through the oral glucose tolerance test. After two hours of that, the doctor finally said she had type 2 diabetes.

The husband said it was getting late and his wife had some errands to take care of the next day. He asked if I could come back after I took my wife to work. He said they needed to learn more about using the computer. As it was, they mostly used it for video and chatting with family and the children at college. I agreed and said goodbye.