medication

Sometimes, one reads a statement so obvious that one needs to ask, “Why didn’t I think of that?” So it was that I read on the blog of Dr David Healy a most obvious observation about medications. “Drugs can have a hundred effects … but we only test for one”.

In medical school we are taught pharmacology. They go into the issue of side effects being those effects of a drug, which we are not wanting. A quick glance at the product information for any pharmaceutical will reveal that aside from the intended effect of the drug there are numerous (indeed sometimes hundreds) of side effects.

Fortunately most people who use medications do not experience major side effects but this may be more good fortune than good planning.

David Healy has written a nine part series on the role of randomized control trials in medicine. The history is fascinating. They were originally intended to ensure a medication was safe rather than effective.

This sort of testing is quite different to the use it came into being, which was testing effectiveness against placebo. In turn Dr Healy argues (and I agree) that doctors and patients have been sold a bit of a pup when we are told that randomized control trial are the gold standard.

The biggest problem we face today is that medications are trialed over a short period of time but used over long periods. Going back 30 years or more, most medications were used short term. The classic example is antibiotics. They are used for week or two. So trials where people are on them for a week are relevant in the real world.

Today most medications are used long term for lifestyle conditions such as high cholesterol, high blood pressure or diabetes to name but three. Trials of these medications may go on for months, even a year or so. However we have no idea what may happen after two, five or ten years of use. It is assumed that they are safe and this is a fair assumption. However this is not the same as saying we know what ten years of use may do to the body that we cannot detect after one year.

My thoughts were turned further on this subject when I heard a presentation at a conference a few weeks ago about long-term use of reflux (heartburn) drugs. In the USA the proton pump inhibitors are soon to carry a black box warning about their effect on magnesium absorption. Some 25% of long term users become deficient in magnesium. This causes muscle pains and is worst in the elderly. The problem will be when they go to the doctor who sees this as a new problem needing another tablet rather than a side effect of an existing one.

On reflection it is obvious that when we interfere with the gut we will effect our digestion and absorption. And these drugs reduce acid in the stomach significantly. The stomach does not produce acid just for the sake of it. It is needed for the breakdown and absorption of food especially minerals.

New work is also showing that our war on the Helicobacter (which is implicated in ulcers and won its chief backer a Nobel prize) has led to an increase in reflux. The bacteria, which is found in over 50% of people is doing something useful too. And when we eradicate it we feel clever but may be too clever by half.

Statin medications (for high cholesterol) have been shown to cause muscle soreness. This is worse in the elderly. It also emerges that it can worsen frailty. And to cap it off they can make it harder to get fit due to their effects on muscles. All this for a medication where the benefits are actually quite slim and which have been way oversold.

Some diabetes drugs (the gliptins) are being shown to damage the pancreas leading to pancreatitis. Common painkillers containing ibuprofen, if used in high doses increase the risk of heart attack (similar to Vioxx which was withdrawn from the market nine years ago).

And studies have also found a link (note not cause and effect – yet) between the use of the SSRI antidepressants in pregnancy and autism. We have seen an increase in both in parallel over the last 20 years. If the same association was noted with alcohol, all the public health officials would be screaming it from the rooftops but because it is a medication – silence!

The worst aspect of this is that in mild and moderate depression the SSRI’s do not actually do anything more than placebo!

So what can we make of all this? Doctors and patients have been convinced of the benefits of medications as a solution to lifestyle problems. We ignore the notion of treating lifestyle problems with lifestyle solutions such as dietary change and exercise or stress management. We have forgotten that there is no such thing as a free lunch.

We need to better assess risk as well as benefit and understand that drugs DO have multiple effects. For each individual, their needs to be an individual risk benefit equation. This may change over time even for the same individual. This can never come from guidelines and protocols so beloved by academics and bureaucrats.

As with all things to do with health – we need to be questioning