Slow Pharmacy

I just read an interesting review of a new book titled, My Mother, Your Mother: Embracing "Slow Medicine."

The author, Dennis McCullough, is a physician in private practice with decades of experience in community, family and geriatric medicine. Dr. McCullough is also a medical school professor who believes in traditional medicine but who in "slow medicine" also advocates the incorporation of humanistic values, complementary, and alternative therapies.

As the review continues, slow medicine is a "family-centered, less-expensive way shaped by habits of cooperation, coordination, and conservation of limited resources" and is "a special commitment undertaken by families and health professionals working together to achieve the very fullest understanding of aging loved ones and their complex, ever-evolving needs."

"Slow Medicine" is an interesting and humanistic concept that considers the elders' wishes and treats them with the respect they most certainly deserve.

I'd like to suggest that a component of slow medicine be called "Slow Pharmacy."

So often the elderly are bombarded with a myriad of medications all at once without giving adequate assessment of the positive, or often negative impact they are having on the patient.

A popular mantra in geriatric pharmacy is "start low and go slow." That is, start out with a small dosage of a new medication and wait to see how it is working. Only then, if the effects are beneficial, a gradual increase in dosage might be warranted.

I believe that "Slow Pharmacy" is an important component of "Slow Medicine" and I'm looking forward to reading this book.

William Simonson, PharmD, FASCP, CGP
http://www.askdrsi.com/

Sleep medicines and falls

Dear Dr. Si

We are working to reduce the number of falls in our facility and are wondering about the role of hypnotic agents. Can all sleep medicines result in falls? – WS, Portland, OR

Dear WS,

The sleep medicines that were used in the past such as the barbiturates Nembutal® and Seconal® were tremendously sedating and not only resulted in sleep, but also caused general depression of the central nervous system, resulting in numerous serious complications, including falls.

Classes of medications developed more recently also contributed to falls with the long-acting benzodiazepine Dalmane® (flurazepam) being one of the biggest culprits. Falls have also been attributed to other benzodiazepines including Halcion and Restoril.

Whether the sleep medications commonly used today such as Lunesta®, Rozerem®, Sonata® and Ambien® contribute to falls is unclear but they certainly seem to be safer than the older products.

A 2005 study of more than 34,000 nursing home residents looked at medication use and falls and found that the use of sleep medicines did not contribute to falls but that insomnia alone was found to be a significant risk factor for falls. These data might indicate that allowing residents to get the sleep they need, perhaps through the use of newer and safer medicines, might actually protect them from falls.

This relationship will have to be studied in more detail to come to firm conclusions but in the meantime, consider sleep hygiene first, including important steps like avoiding caffeine just before bedtime, before considering the use of sleep-inducing medications. And, if a drug is used, it should be at the appropriate “geriatric dose,” with close monitoring of the patient for side effects, such as confusion or sedation that could possibly lead to falls, and, of course by making sure that the product is used according to its instructions. Avoid chronic use and also, avoid using sedating medications such as Elavil® (amitriptyline) and Benadryl® (diphenhydramine) to induce sleep because of multiple side effects that can contribute to falls. ***

How to take Actonel and related osteoporosis medicines

Dear Dr. Si,

I have a patient who likes to take her Actonel® with a glass of orange juice in the morning, but the administration instructions state that it should only be given with water. Does it really make a difference whether I give it with water or juice? SM, Milwaukie, WI

Dear SM,

Actonel® is a member of the bisphosphonate drug class used to increase bone mineral density in people who are osteopenic or osteoporotic, ideally strengthening bone and preventing fractures. All of the oral medications in this family, including Fosamax® (alendronate), Actonel® (risedronate), and Boniva® (ibandronate) are similar in that they can cause irritation in the esophagus and stomach, which can be extremely dangerous.

Each of these products must be given with a full glass of water and the patient must remain upright for at least 30 minutes with Fosamax® and Actonel®, and at least 60 minutes with Boniva®. The water washes the tablet down the esophagus to reduce the chance of irritation.

Another similarity between these products is that they are all very poorly absorbed into the bloodstream after oral administration. In fact, normally less than 1 percent of these products is absorbed!

Further, it has been determined that if any of these products are taken with anything other than water (such as juice or coffee), any type of food, including small amounts of apple sauce or pudding, or any other medications, the absorption will be decreased. In fact, essentially no medication will be absorbed. So you must to give Actonel®--or Fosamax® or Boniva®--with water and only water to ensure that the patient gets the full benefit of the medication. ***

Should I stop taking Vytorin?

Dear Dr. Si,

I recently read that Vytorin® is ineffective. I have been taking it but am considering stopping it. What do you think?- AK, Chicago, IL


Dear AK,

Vytorin® is a combination product for control of lipids that contains the active ingredients from the prescription medicines Zocor® (simvastatin) and Zetia® (ezetimibe). Combining both of those medicines in one tablet makes sense because each drug has a different mechanism of action – Zocor® inhibits the production of cholesterol in the body and Zetia® impairs the absorption of dietary cholesterol.

However, recently, the preliminary results of the ENHANCE trial were published and researchers found that the combination was apparently no more effective than using Zocor® all by itself.

These findings were a surprise because we would expect the combination of two cholesterol lowering medications to work better than a single drug.

The media got hold of the story and probably made it more of a big deal than they should have because the patients studied had an uncommon form of familial hypercholesterolemia that resulted in very high cholesterol levels, and the data is just preliminary so it may take years before we know the real answer.

In my opinion, I would not recommend that Vytorin® be discontinued based on this study because there is no evidence that Vytorin® causes excessive harm and there is plenty of evidence that lowering cholesterol has very favorable outcomes.

Risk Versus Benefit of Drug Therapy

When it comes right down to it, drug therapy is a huge risk-benefit exercise that requires a serious consideration of the potential benefits, balanced by the potential risks of that therapy.It might make sense to use a high risk medicine if the benefit is great enough. For example, if a patient has cancer that could respond to chemotherapy, it might be a reasonable decision to start that therapy, in spite of its potential risks.On the other hand, it might make sense to use a medicine that is only partially effective for a condition, as long as it is associated with minimal adverse effects.A situation that you probably want to avoid is the use of a medicine that offers few benefits, but has a high risk of complications such as adverse reactions or drug interactions.So, whenever your physician wants to start you on a new medicine ask these three basic but most important questions: What is the potential benefit of the medicine? What are the potential risks? AND, are the risks worth the potential benefit?