Issues to Think About When Taking Numerous Medications
Guest: Dr. Bill Simpson – Family Medicine
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda Austin,
interviewing Dr. Bill Simpson who is Professor of Family Medicine here at
Medical University of South Carolina.
Dr. Simpson, you do a lot of work with older patients. And, anybody who has helped an older relative
knows how easy it is for older folks to find themselves on three medications,
eight medications, fourteen different medications. What are some of the special issues that
older people need to think about, especially when they’re on multiple
Bill Simpson: Well, I think the main
thing the elderly population needs to do is to be satisfied if the doctor takes
away a medicine. One of the most
frequent things that I do when I see people having trouble is stop a
medicine. Many times a person has had
one complaint and they get treated for that.
Then they come back for a different complaint, which is probably a
reaction or a secondary side effect of the medicine they’ve been given. And instead of stopping the medicine, the
physician doesn’t recognize that it’s a side effect and adds a second medicine,
or a third medicine, or a fourth. And so
the patient begins to take more and more medicine, or may begin to take more
and more medication, treating a side effect of a previous medication. So, encourage the elderly person, anybody, in
fact, who’s taking medicines, multiple medicines, to think about the
possibility that it might be the medicine that’s doing the harm.
certainly don’t want people to stop taking their blood pressure medicine or
their medicine for their diabetes or arthritis, but to think about, especially,
medicines given for a temporary problem, or a short-term problem, or an acute
problem that’s just happened now, and try to figure whether or not it’s
necessary to have that medicine for very long, or at all. Each time we add another medicine to the list
of medicines a patient takes, the risk of a drug-drug interaction, or a
drug-food, or a drug-disease interaction increases. So, the fewer medicines we take overall, the
better it is.
Linda Austin: Now, are elderly folks
more susceptible to these side effects just by virtue of being older, or is it
because they have more medical conditions, or because they’re taking more
Bill Simpson: It’s multiple yes’s, I
think. They’re older. They have somewhat decreased ability to
handle medicines, to detoxify medicines, to take care of medicines. The kidneys and the liver don’t function
quite as well as they once did, so there’s more risk of rising drug levels or
interacting drugs. So, that certainly is
one thing. It’s just a function of the
number of medicines. The more medicines
you take, the more risk there is of an interaction. But, certainly, being older is an additional
Linda Austin: Are there any common
medications that you see in your clinic coming up over and over again as causing
side effects in older people?
Dr. Bill Simpson:
Well, the antihistamines, decongestants can and they’re very widely
used. The antihistamines because of
sedation, which occurs with antihistamines, which are oftentimes given for an
allergic reaction or for a cold, or congestion, hay fever, those sorts of
things. They may make the person sleepy
and, therefore, more likely to fall or injure themselves. The decongestants cause constriction at the
bladder neck, so a male, an older male, who has prostate problems, who’s given
a decongestant, may have more difficulty urinating from that. That’s a fairly common interaction from a
very commonly used medicine.
I guess the one that’s most dangerous is the
coumadin, the person who’s on coumadin, a blood thinner, which makes people at
risk for problems along the way. But
then they have a mild infection and they’re put on antibiotic. And the antibiotic, in particular, is Septra,
or a sulfa drug, Trimethoprim, Sulfamethoxazole. And that can significantly raise the level of
the anticoagulant effect of coumadin in the blood. So it’s one of the most common of the drug
interactions that causes major difficulties.
That’s not that common. But coumadin is used a lot for a lot of
folks. And sometimes the physician
forgets that the patient is on coumadin or doesn’t remember, or doesn’t look
carefully at the list. So, they have a
urinary tract infection and Septra is the most commonly used drug, or among the
most commonly used drugs, so they just get put on it. And the next time their coumadin is checked,
it’s four times what it was before.
Dr. Linda Austin: Now, I know, in my field, in Psychiatry, we
often use half or, sometimes, a quarter of the dose in older folks, older being
80, 85 years and older, relative to a young adult, because brains are more
sensitive, and because livers are more sluggish in metabolizing
medication. Is that a rule of thumb in
other areas as well?
Dr. Bill Simpson: That’s a pretty good rule of thumb, to be
cautious, to start low and go slow.
That’s what we always say, start with a low dose and raise it very
slowly, depending upon the person’s response to the medicine.
Dr. Linda Austin: Do you have any particular tips for older
people who are interested in decreasing the likelihood of side effects?
Dr. Bill Simpson: I think, probably, the most important thing
is to have one pharmacy that fills all your prescriptions from whatever
physicians you see, so that one pharmacy knows everything that you’re on. They’re the ones who are most likely to be
able to pick up the drug-drug interactions.
Dr. Linda Austin: Because they put that information into a
computer and the computer tells them what the interaction is.
Dr. Bill Simpson: Exactly.
And, certainly, it used to be that only a few pharmacists had the
benefit of a drug-drug interaction program and kept profiles on their
patients. Now, almost all do. If your pharmacy doesn’t keep a profile and
know all the medicines that you’re on, tell them you really want them to and
encourage them to get a drug-drug interaction program too.
Dr. Linda Austin: I think that’s really important advice
because I know, as a physician, there are so many new medications coming out
every year and it’s, frankly, impossible for any of us, as individuals, to know
all of the thousands of different interactions that there could be, and we
really rely on those computers to give us that information.
Dr. Bill Simpson: Definitely.
Dr. Linda Austin: Thank you so much, Dr. Simpson.
Dr. Bill Simpson: Thank you.
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