Medication: Issues to Think About When Taking Numerous Medications

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Medication: Issues to Think About When Taking Numerous Medications




Guest:  Dr. Bill Simpson – Family Medicine

Host:  Dr. Linda Austin – Psychiatry


Dr. 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 medications?


Dr. 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.


We 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.


Dr. 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 medications?


Dr. 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 risk factor.


Dr. 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.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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