Are You Very Afraid of Interactions – The Health Care Blog

By HANS DUVEFELT

I happened to be reading about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this most common diuretic and risperidone: Elderly dementia patients who take risperidone have twice the expected mortality when given furosemide as well. I knew that all atypical antipsychotics could double mortality in elderly dementia patients, but I wasn’t aware of the additional risk of risperidone furosemide. Epocrates only has a non-specific warning to monitor blood pressure when both drugs are prescribed.

This is just today’s example of an interaction that I didn’t have on hand. I very often check Epocrates on my iPhone for interactions before I prescribe because – frankly – my EMR always gives me one whole screen with idiotic kindergarten warnings in the fine print, no one ever has time to read it in a real clinical situation. (In my case, from the otherwise decent manufacturers of UpToDate.)

I keep coming back in my mind and blogging about it Drug interactions. And every time I come across someone who has surprised me or caused damage, I think of the inherent, exponential risks of Polypharmacy and the virtues of oligopharmacy.

One conclusion I’ve come to is that the benefits of our prescribed drugs are too often: actually too small to justify the drug. Pretty much the way drugs are approved today is that they must have about a 20% advantage over placebo for a given result. Aside from the drug versus placebo, all other factors are ignored or “controlled” which is easier said than done.

But this whole premise seems wrong to me: if Pill A is better than placebo at lowering blood pressure by 20%, but salt restriction, weight loss, exercise, and stress relief are twice as potent as Pill A, then why are we sticking to the prescription like this? Pill A? When a Mediterranean diet lowers cardiovascular risk just like atorvastatin, why is this not a blockbuster / a piece of cake?

Our nation’s health is not good despite all the pills available to us. And the more pills we prescribe, the more we risk interactions: antidepressants and cholesterol pills with blood thinners, gout medications with cholesterol pills, mood stabilizers with heart medication, and so on and so on.

May we all take a step back and look at the bigger picture of what we are doing and where we are going.

Donald W Light of the Harvard Center of Ethics wrote in 2014:

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they’re approved. For this reason, knowledgeable doctors recommend not taking new medications for at least five years unless patients have previously tried more established options and are required to do so.

Few know that systematic reviews of hospital charts have found that even properly prescribed drugs (other than misprescription, overdose, or self-prescription) cause approximately 1.9 million hospital admissions per year. Another 840,000 hospitalized patients receive drugs that cause serious side effects for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from the drugs prescribed for them. This makes prescription drugs a major health risk, ranking fourth with stroke as the leading cause of death. The European Commission estimates that prescription drug side effects cause 200,000 deaths; combined, approximately 328,000 patients die from prescription drugs in the US and Europe each year. The FDA does not recognize these facts and instead collects a small fraction of the cases.

There are obviously more recent statistics, but I noticed this article because it was posted on a forum about ethics. Think about it for a moment: we expose our patients to known and unknown risks of harm with every prescription we issue.

Hans Duvefelt is a Swedish born rural family doctor in Maine. This post originally appeared on his blog, A Country Doctor Writes. here.