Monday, March 4, 2019

Yes, you DO need to take that pill

Over the past 60 years we have come a long way in treating many conditions in ways that prolong life and health. Perhaps this is best exemplified by the approach to high blood pressure (“hypertension” or HTN). History buffs may be aware that Franklin Delano Roosevelt died of complications of HTN. In 1937, when FDR was 54, he had a BP reading of 162/98, but the prevailing medical opinion at the time, espoused by such eminent men as Paul Dudley White, was that HTN should be considered necessary and not be treated. Even had his physicians wanted to lower FDR’s blood pressure, there were no effective ways to do so at the time. As was the rule in those days, his BP rose inexorably and he subsequently developed heart failure and had a series of small strokes, and finally died of a massive brain hemorrhage.
Life insurance companies were aware as early as the 1950s that people with HTN died prematurely and refused to insure them, and the medical profession belatedly began to connect untreated HTN with heart and kidney failure and stroke, and effective medicines to lower blood pressure became available. Since the 1950’s there has been a dramatic reduction in HTN-related illness and death.
Another area where preventive medicine has made enormous strides is in lowering cholesterol and preventing coronary artery disease. Added to this has been the drop in the number of people who smoke, another major factor in causing heart attacks. When I was an intern and coronary bypass surgery was in its infancy, the recipient of successful coronary grafts was often told “see you again in 10 years,” as little was done to modify the factors that had brought them to the catheterization lab and surgery. Nowadays, with aggressive risk factor control, the CABG patient may be good for 20 years or more.
Osteoporosis is another condition that now has multiple available treatments that have been shown to reduce fractures that add to disability and death.
The common thread among all these conditions is that the medicine must be taken to work! About 70% of Americans have been prescribed a medication for chronic use and more than half take two or more. Despite the overwhelming evidence that these medicines, when properly prescribed and regularly taken, extend life and prevent disability, nearly half of us do not take our medications as prescribed. Surveys show that half of us missed at least one dose, one in three could not remember if they had taken a medication and 25% did not refill a prescription when it ran out. Even participants in clinical trials, who are followed much more closely than are patients under routine care, often stop taking the study drug.
The reasons people do not take medications as prescribed fall into several categories. The most obvious potential cause, cost, is one of the less common reasons given. For any individual patient cost can be a huge factor, but cost is only cited as the reason for non-compliance by about 16%. A similar number stop because they are concerned about side effects or by something they have read (often on the internet!). Many people stop taking their medication because they do not feel any better and do not feel it is worth the bother. This is certainly true for HTN, osteoporosis or high cholesterol, which are symptom-less conditions until they are far advanced. The commonest reason of all is simple inattention, forgetfulness.
Non-compliance, according to estimates in a study published in the Annals of Internal Medicine in 2012, may add $100 billion to our national health bill due to preventable hospitalizations as well as many premature deaths. The most recent data shows that patients with coronary disease who were less than 50% adherent with their "statin" had a substantially (30%) higher death rate than those who were more than 90% adherent.
What can you do? First, if your doctor prescribes a new medication, be sure to ask why it has been prescribed, what you should expect to see, good or bad, and if there are alternatives should it not agree with you. Ask what to do if you forget a dose: should you double up or just get back on schedule? If you get sticker shock when you go to the pharmacy, refuse the medicine. Once you have walked out with it, they cannot take it back, but either you or the pharmacist can call your doctor and ask if a less expensive alternative would work. If you experience what may be side effects, do not simply stop but call your doctor and discuss these. Do NOT take frightening tales you read on social media as the truth and discuss these with your doctor or pharmacist before acting on them.
Finally, make it easy for yourself. Put the pill bottle out where you can see it – that may be on the bathroom shelf or the kitchen table, but it should not be in a cabinet or drawer. If you are taking several pills, particularly if they are taken at different times, use a pill organizer which you can fill once a week and then leave it out in an obvious place. (And ask your doctor if a simpler schedule would work as well!)

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  1. No one can argue with taking your anti-hypertensive because the morbidity/mortality statistics have been in for a long time. Many of these other medications justify themselves by treating numbers rather than outcomes (e.g., statins for primary prevention). Many have horrific side effects that patients are not informed of (bisphosphonates for osteoporosis). And none of these meds have been put up against lifestyle changes in RCTs, because for many of them lifestyle changes would handily beat meds in improving outcomes (weightlifting for osteoporosis, quit-smoking-and-lose-weight versus cardiac and diabetes meds, and so on). And since drug companies pay for the research, we can't expect to see such trials anytime soon. Physicians have not taken an adequate self-appraisal for their role in uncritically passing on as good coin the drug companies' thoroughly compromised research. And let's not even get into how doctors helped Pharma hoodwink everyone about opioids for decades while the deaths continued to pile up, without the benefit of any supporting research at all. The drug research is hopelessly undermined and falsified in the service of greater drug sales. For decades, women and minorities were excluded entirely from trials, and it is still rare as hens teeth to find one that reports separately the outcomes for women and minorities. Drug companies are still publishing the one study that shows a vanishingly small edge for their med against the me-too meds, while burying the research studies that show otherwise. Tip of the iceberg: The recent scandal at Sloan Kettering where the top cancer doctors hid the millions they were raking in from drug company board memberships, shares in start-ups, and other payments from Pharma. These are the same guys who head the studies, write the journal articles, and create the clinical treatment guidelines. It should be a scandal and yet...somehow it's not. Business goes on as usual. Patients deserve better.

  2. I agree with much of what you say, but lifestyle changes have dismally poor track record for compliance. The best weight loss studies show 5-10 pound weight loss in people who need to lose 50. I heartily endorse supporting the 1 in 10 who can accomplish their lifestyle goals, but we also have to care for the other 9!

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