An Editorial in the American Journal of Medicine (August 2017) is entitled ” Poly-pharmacy in Elderly Patients:the march goes on and on”. The Journal succinctly states that “it is as common as dirt” in the USA and that “itrears its ugly head in all resource-rich countries where patients, particularly elderly individuals have ready access to prescription and over-the-counter drugs”.
But I would like to point out that poly-pharmacy is as common and intolerable as dirt and needs to be swept awayin Myanmar also, not only in the elderly but in patients of all ages, rich and poor. Why is it so common?
Largely because treatment is seldom based on a specific disease but on symptoms; doctors may not have the means or the inclination or time to make a rational diagnosis and so resort to administering a drug for each symptom. This has been made easier since ready packed patent medicines have replaced the outmoded, pre-WW II method of writing prescriptions for mixtures and powders and pastes which are prepared and dispensed by a compounder present in every hospital and clinic.The number of drugs dispensed multiplies if and when doctors add any secondary drug(s) of dubious value for the disease being treated – particularly vitamins which are the commonest such additives. A patient with Typhoid fever will be given the definitive treatment which is the antibiotic Ciprofloxacin orally but then multivitamin injections may be added unnecessarily, and may be potentially dangerous if given intravenously as a vitamin cock-tail.
But another reason for poly-pharmacy and administration of an unnecessary or irrational, outmoded therapy which is not evidence-based may be just inertia orintellectual laziness; this is the case when Injection Vitamin C and K are prescribed routinely for any bleeding whatever the cause even if there is no reason to suspect that the patient suffers from some liver pathology that may cause Vitamin K deficiency and contribute to the pathogenesis of bleeding. My friend, a well-known surgeon and teacher re-calls a memorable episode that occurred when he was working in the UK (about 50 years ago). A patient had come to the Emergency Department for some simple bleeding such as a nose-bleed or slightly prolonged bleeding after a tooth extraction. (I don’t remember what) and the doctor on duty had prescribed Injection Vitamin C& K. When the Consultant found this out, he was understandably wild with rage and told my friend that he knew at once this was done by a Myanmar doctor because it had happened so frequently before. My friend was chagrined that our doctors had gone and committed such irrational practices in the UK. I thought that such habits have gone away from Myanmar but to my deep disappointment I saw the same irrational therapy being given in a hospital a few years ago. Something is wrong somewhere.
Multivitamins are the most popular and frequently used drugs that contribute most to poly-pharmacy. It is added as supplement to almost all specific medications. Moreover, it is purchased over the counter and consumed in huge quantities by the gullible public as ‘tonic’ (Aar-say); and encouraged by doctors to do so even if the patient or person who seeks advice has no evidence or likelihood of vitamin deficiency, especially in the case of the elderly.Administration of safe but pharmacologically ineffective vitamins as placebo is another reason for poly-pharmacy but this is a different issue and will not be discussed now. Much has been written in MJCMP and elsewhere about the misuse of vitamin therapy not only in Myanmar but also in other countries, even in the UK. It is laughable but regrettably true when we hear anecdotes about patients asking for and doctors giving a shot of Injection Vitamin B12 1000 micrograms as tonic before a game of golf – 900 micrograms in excess of the daily requirement and which will therefore be excreted in the urine.
Another possible reason for poly-pharmacy is that in Myanmar, most doctors doing single general practice in their own private clinics do not charge and receive consulting fees. It is not a fee for service system but fee for drug. So, consulting fees are recovered as part of the total charged for the drugs administered and the more drugs administered means more profit. Doctors have to purchase drugs wholesale and make a small profit out of what they dispense retail in-lieu of consulting fees.
The Editorial in the American Journal of Medicine points to the negative side of poly-pharmacy. It reveals the high cost as well as other detriments to patients such as large number of adverse events and potentially dangerous drug-drug interactions.All this is compounded in the elderly who have multiple diseases and need multiple-therapy.
But then there is also the issue of whether a disease in an elderly requires any treatment at all.The Editorial refers to an article where the authors observed that “many of the drugs prescribed were given for long-term preventive therapy such as statins or anti-hypertensive medications. Given that many of these patients were chronically and severely ill and not expected to live for many more years, the value of preventive medicine at that stage in life is clearly questionable. For example, it is likely that moderate hypertension will not harm an elderly patient with end stage disease. Therefore an aggressive antihypertensive medication program in such a patient is not needed”.
Similarly, a frail or even an otherwise relatively healthy, non-frail, elderly patient of 70 years or more with Type 2 Diabetes may not need strict blood glucose control especially if insulin is required. The risk of hypoglycemia is more than that of vascular complications 4-5 years later.
AReview in the Cleveland Clinic Journal of Medicine (February 2017) concluded that “evidence does not support lipid lowering therapy for severely frail elderly patients” (that is, patients who require assistance with basic activities for daily living, such as bathing or dressing owing to cognitive or physical defect from any cause).
The Review recommended that: “there is no reason to prescribe or continue statins for primary prevention; statin treatment is probably not necessary for secondary prevention;thereis no reason to start or continue statins for heart failure”.The Review also stated that some experts may ask “What is the harm in using statins, even if there is no definite benefit?”But the authors of the Review, after balancing the harms and the benefits, disagree and say that “less is more.”We in Myanmar who tend to use the same argument tojustifythe multiple use of dubiously effective drugs, saying that “even if there is no definite benefit why not use if there is no harm”should beware of the high probability that this may lead down the slippery slope to cost-ineffective, cost-inefficient, loose, irrational poly-pharmacy.
Prof: Aung Than Batu
