Be courageous: help stop the pill madness

Medicine people give it a sterile-sounding name. Polypharmacy means giving too many drugs, usually to an elderly person.

But this practice is worthy of clearer words: dumb, dreadful or doctoring at its worst.

The idea to mention the growing problem of giving too many pills in combination came to me after reading this Medscape coverage of a trial of statin removal in patients nearing end of life. The randomized clinical trial was presented at the 2014 Annual Meeting of the American Society of Clinical Oncology. One group of patients had their statin stopped and the other group continued the drug as is the normal practice. The researchers found no difference in mortality but they did note patients in the discontinuation arm reported an improved quality of life and a trend toward fewer symptoms. A cost analysis showed major savings, and if this practice took hold over large populations, savings to the health care system would be immense.

That we need a study to tell us it’s okay to stop non-evidence-based pills is telling. I’m not sure where commonsense got lost. These chemicals, such as statins, ACE-inhibitors, beta-blockers, were shown to be beneficial in the setting of clinical trials of patients who were not elderly, frail, encumbered by cancer, demented or close to death.

Take the statin trial from the cancer meeting. Of course there was no difference in mortality from stopping the drug. Depending on the risk of the patient (high-risk–more benefit, low-risk–less benefit), statin drugs confer protection from cardiac events of 1-3% over 5-10 years. If you have life-limiting disease, such as dementia, cancer or frailty, that 1-3% statin benefit over 5-10 years is not helpful to you. You get all the harm and none of the benefit. (In fact, for many of these patients, some in diapers and with delirium, a cardiac event might be considered a blessing.)

Another example is ACE-inhibitors. These blood-pressure reducing drugs have proven benefit in patients with congestive heart failure. But again, they were not studied in the frail, elderly and chronically ill. A common problem in the elderly is unsteadiness of gait. Low blood pressure contributes to this problem and stopping blood pressure medications (that may have once been helpful) often works wonders. “Are you dizzy when you stand-up” is a question I ask every old patient in the office. I see my yearly visit with patients as an opportunity to stop drugs that are not beneficial. This tree often bears low-hanging fruit.

One thing Staci has taught me about pill burden is that patients admitted to palliative care and hospice services often flourish when their “nonsense” medications are stopped. She teaches me that the chronically ill and elderly need most to eat food not pills. This is perhaps one of the reasons why some studies show patients started early in their course on palliative care live longer. Of course they do.

Many of the drugs we use now as if decried from gospel (statins, ACE-I and beta-blockers) were studied in the 1980s and 1990s, a time when many fewer drugs were on the market. Nowadays, it’s common for an elderly patient to be taking more than ten medications. Think about that. That’s ten chemicals that can interact with each other, sometimes increasing effect and other times decreasing effect. That’s ten pills to be cleared by the kidneys or liver, whose filtering functions diminish with aging.

Doctors (and patients) should not need a carefully designed trial to give us permission to practice minimally-disruptive commonsense medicine.

Please, let’s stop the madness with the pills. To do no harm does a lot.

JMM