A study of 5,815 elderly Medicare patients indicated that 22 Percent Received Pharmaceutical Prescriptions that Might Have Worsened One of Their Multiple Medical Conditions — the Take Away Is that the Therapeutic Cost-Benefit Ratio for Drug Combinations Needs to Be Assessed for Each Patient

14 March 2014

Citation — to study

Songprod Jonathan Lorgunpai, Marianthe Grammas, David S. H. Lee, Gail McAvay, Peter Charpentier, and Mary E. Tinetti, Potential Therapeutic Competition in Community-Living Older Adults in the U.S.: Use of Medications That May Adversely Affect a Coexisting Condition, PLoS ONE, DOI: 10.1371/journal.pone.0089447 (25 February 2014)

Patients on multiple prescription drugs need to pay attention to what their physicians prescribe

For many people, what is (or has been) prescribed might be bad for one of their medical conditions:

In this nationally representative sample of older adults in the U.S., over 20% took at least one medication that could adversely affect another of their chronic conditions.

Because MCBS [Medicare Current Beneficiary Survey] is a nationally representative sample, study estimates reflect the prevalence of potential therapeutic competition in the older U.S. population.

The frequency of potential therapeutic competition is likely related to the high prevalence of multi-morbidity in older adults combined with the focus of disease guidelines on medication benefits for individual conditions.

© 2014 Songprod Jonathan Lorgunpai, Marianthe Grammas, David S. H. Lee, Gail McAvay, Peter Charpentier, and Mary E. Tinetti, Potential Therapeutic Competition in Community-Living Older Adults in the U.S.: Use of Medications That May Adversely Affect a Coexisting Condition, PLoS ONE, DOI: 10.1371/journal.pone.0089447 (25 February 2014) (at Abstract and first paragraph under Discussion)

The potential therapeutic conflict is not necessarily undesirable, as evaluated within individual patients’ overall contexts

However, cost-benefit weighting should be knowledgeably assessed:

It is likely that many of the individuals experienced net benefit from the medications despite the presence of a competing condition.

The presence of competing conditions does not imply contraindication of the medication but rather the need for clinicians to weigh the effects of medications on each of a patient's conditions, not just the condition for which it is recommended.

Unfortunately, such evidence is lacking currently for many medications and chronic conditions.

Studies of medication effects should include equally rigorous ascertainment of harms as well as benefits, not just on the disease of interest but on commonly co-existing conditions.

A chemical and biological premise

In school, our pharmacology professors insisted that, statistically speaking, anyone on 5 to 7 drugs was going to experience drug conflicts — meaning that one or more of the pharmaceuticals would weaken or aggravate the effect of another drug — or, alternatively, one or more the prescriptions would biochemically aggravate one of the patient’s existing medical conditions.

As the above cited paper implies, short appointment times and the Medical Establishment’s tendency to concentrate on one patient problem at a time makes a mess of this (chemical) common sense lesson.

How the study was done — credible work

The research team looked at 2007-2009 Medicare Current Beneficiary Survey data for 5,815 patients.

Thirty-four percent of the sample was 80 or older, and 56.4 percent were female:

[W]e included all cohort members who:

1) were age 65 years or older,

2) did not reside in a skilled nursing facility (medication data was not available for skilled nursing facility residents),

3) completed the in-person interview during which medications were ascertained,

and

4) participated in the traditional fee-for-service Medicare.

The chronic conditions meeting study criteria included:

atrial fibrillation,

benign prostatic hypertrophy (BPH),

coronary artery disease,

chronic obstructive pulmonary disease (COPD),

dementia,

depression,

diabetes (type 2),

gastrointestinal esophageal reflux and peptic ulcer disease (GERD/PUD),

heart failure,

hyperlipidemia,

hypertension,

hypothyroidism,

osteoarthritis,

and

osteoporosis.

We determined the frequency of all pairs of these chronic conditions experienced by study participants.

The most common chronic patient problems were:

hypertension — 68.4 percent

hyperlipidemia — 59.6 percent

osteoarthritis — 49.1 percent

The most commonly prescribed drugs were:

ACE inhibitors or angiotensin receptor blockers — 44.0 percent

statins — 45.7 percent

beta blockers — 40.5 percent (of which 76.8 percent were the selective type)

Critically important — and the key to understanding the study’s findings

The overwhelming majority of the patient sample (4,542 patients) —78.1 percent — had one or more pairs of chronic conditions:

65.0 percent had 3 or more pairs

and

31.4 percent had 10 or more pairs

One can conclude that having just one medical problem is a rarity in the Medicare group.

That phenomenon should ring some prescribing practice alarms.

Oops

After pairing up the 91 chronic conditions with the drugs that are generally used to treat them, the research team concluded that:

1,313 people — 22.6 percent — had been prescribed one or more medications that potentially made another of their medical problems worse

286 patients — 4.9 percent — had 2 such therapeutic conflicts

and

468 — 8.1 percent — had 3 or more.

There is no way to tell from the data, whether an overseeing physician had calculated the likely therapeutic cost-benefit ratio for the whole kaboodle of drugs that had been assigned to each patient

Based on personal experience with the medical system, I would guess not.

The research team appears to agree. Recall that, although they emphasized that the benefit of a conflicting medication may outweigh its harms, they implied that the Medical System’s preference for seeing one problem at a time might work against physicians making the necessary “totality” calculation.

Furthermore, research has not analyzed the good and bad effects of prescribing multiple medications to patients who have commonly coexisting medical conditions.

The moral? — Research, yes, plus . . .

In my somewhat knowledgeable opinion, our medical system underestimates the contributions that pharmacologists, pharmacists and competent computer-based prescribing software could contribute to patient care.

The above study hints that way.

PeteFree.com

A study of 5,815 elderly Medicare patients indicated that 22 Percent Received Pharmaceutical Prescriptions that Might Have Worsened One of Their Multiple Medical Conditions — the Take Away Is that the Therapeutic Cost-Benefit Ratio for Drug Combinations Needs to Be Assessed for Each Patient