HAZARDOUS AND INAPPROPRIATE DRUGSPrescription Drugs and the Elderly
July, 1995. GAO/HEHS-95-152 Single copy of the report is gratis; additional copies, $2. each. Order free copy from U.S. General Accounting Office, PO Box 6015, Gaithersburg, MD 20884 Order paid copies with check or money order to: Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402 (25% discount on bulk orders of 100 or more copies mailed to a single address)
A study in 1987 concluded that nearly one out of four non-institutionalized elderly patients were taking prescription drugs that, according to many experts, were generally unsuitable for their age group. Alternative drugs could provide the same therapeutic benefits with fewer side effects. This high percentage would be even greater if other situations would have been included, such as potentially dangerous drug interactions, or incorrect dosages.
A more recent analysis, in 1992, from data supplied by the Medicare Current Beneficiary Survey, showed slight improvement, but a generally appalling situation. About 17.5% of almost 0 million non-institutionalized Medicare recipients 65 years or older used at least one drug identified as generally unsuitable for the elderly, with safer alternative drugs that could have provided the same therapeutic benefits with fewer side effects.
The inappropriate use of prescription drugs may cause unnecessary adverse drug reactions that can lead to subtle deterioration of function or precipitate medical crises resulting in hospitalization or death. They contribute to higher medical costs. The Food and Drug Administration estimates that the annual cost of hospitalizations due solely to inappropriate prescription drug use is $20 billion.
The inappropriate use of prescription drugs is particularly acute for the elderly. They use more prescription drugs than any other age group, and are more likely to be taking several drugs concomitantly, thus increasing the probability of adverse drug reactions. Furthermore, the elderly are at greater risk than other age groups because they do not eliminate drugs from their systems as efficiently, due to decreased liver and kidney function
Inappropriate drug use can result from physicians using outdated prescribing practices; from pharmacists not performing drug utilization reviews; and from patients who fail to inform their physicians and/or pharmacists about the total number of drugs they are taking. Several recent actions may help to reduce the problem. Federal and state initiatives have encouraged the development and dissemination of detailed information on the effect of prescription drugs on the elderly. The medical community has begun to emphasize the need to increase physicians' knowledge of geriatrics and elderly clinical pharmacology. The utilization review systems now permit prescriptions to be evaluated to identify potential problems of interactions or detect inappropriate dosages. Patients have begun to seek information from consumer advocacy groups, state agencies, and pharmaceutical companies.
The GAO report includes a list of 20 drugs generally considered inappropriate for the elderly, and suggests alternative drugs that should be considered. Tranquilizers such as Diazepam, Chlordiazepoxide, Fluazepam, and Meprobamate could be replaced by shorter-acting Benzodiazepines as safer alternatives. Medications to induce sleep and reduce anxiety, Pentobarbital and Secobarbital could be replaced by safer sedative-hypnotic medications.
Amitriptyline, used to treat depression, could be replaced with other antidepressant medications that cause fewer side effects. Indomethacin and Phenylbutazone, used to relieve the pain and inflammation of rheumatoid arthritis, could be replaced by other nonsteroidal anti-inflammatory agents that cause less toxic reactions. Cyclobenzaprine, Methocarbamol, Carisoprodol, and Orohenadrine, used to relieve severe pain caused by sprains and back pain, were all judged to be minimally effective for these purposes, while causing toxicity.
The potential for toxic reaction was judged to be greater than the potential benefit. Isoxsuprine and Cyclandelate (no longer available in the U.S.), used to improve blood circulation, were judged to be ineffective. Chlorpropamide, used to treat diabetes, could be replaced by other oral hypoglycemic medications with shorter half-lives and do not cause inappropriate antidiuretic hormone secretion.
Propoxyphene, used to relieve mild to moderate pain, could be replaced with other analgesics that are more effective and safer. Pentzocine, used to relieve moderate to severe pain, could be replaced with other narcotic medications that are safer and more effective. Dipyridamole, used to reduce blood-clot formation, could be replaced with safer alternatives. Its effectiveness at low dosage is doubtful, and at higher doses, there are toxic reactions. Trimethobenzamide, used to relieve nausea and vomiting, was judged to be the least effective of available antiemetics.
Editor's Comment: Although the government report criticizes amitriptylene (imipramine) as being appropriately replaced by other antidepressants, imipramine works well in many individuals and should not be arbitrarily replaced. Except for dry tongue, imipramine does not have many side effects. Jonathan Collin, M.D.
(Reprint, Townsend Letter for Doctors and Patients, June, 1996 edition)
THE SAN FRANCISCO MEDICAL RESEARCH FOUNDATION
Copyright © 1996. The Light Party.
| Top or Page