Patients with chronic ailments are normally told – ‘keep taking the tablets’. But when does it make more sense to actually STOP taking the tablets?
The question has come under the spotlight recently with a controversial plea for GPs to no longer prescribe medicine such as statins (for high cholesterol) and anti-hypertensives (for high blood pressure) to those over 80.
The rationale is that when patients get to that age the risk of side-effects from the multiple daily drugs many take begin to outweigh the declining clinical benefit.
Dr Kit Byatt, a specialist in geriatric medicine at The County Hospital, Hereford, recently provoked debate when he wrote a viewpoint piece in the journal Evidence Based Medicine imploring doctors to withdraw treatment and allow the very elderly to die naturally, rather than have a prolonged life dominated by unpleasant side-effects.
He argued many older people see death as the next natural event in their lives and do not want the burden of medication, especially if it is likely to have a negative impact on their quality of life.
It is estimated that more than two million people over 80 in Britain are currently prescribed pills to prevent strokes and heart attacks, with many drugs causing debilitating side-effects.
For example, statins are known to cause headaches, nausea, muscle pain, nosebleeds and cold-like symptoms. Meanwhile, high blood pressure pills, like beta-blockers, can cause dizziness, blurred vision and fatigue. One recent study by experts at Yale University showed high blood pressure tablets greatly increased the rate of fatal falls in the elderly.
Side-effects apart, some research suggests the older the patient is, the less likely the drugs are to work. But many will continue tasking them because they come from an era where it was unacceptable to offend the family doctor by refusing medication.
Dr Byatt wrote: “The data strongly suggest that we are over-treating many over-80s. The largest trials of antihypertensive therapy and statins in this age group show at best a marginal clinical reduction in stroke and very modest clinical reduction in other cardiovascular end points.
“In my experience, it is not uncommon in the oldest of these often frail but relatively disease-free patients, to see death as the next natural event in their life, especially welcome if they have outlived their peers.
“However this cohort is often deferential to the doctor, whom they frequently want to please or at least not upset. Most of the patients will probably eschew the modest potential benefits, preferring the reduced burden of polypharmacy and side-effects.”
But not everyone agrees.
The Stroke Association said talking through the available treatment options with patients was crucial.
But a spokesman added: “It is vital that people at risk of stroke, and who could benefit from these types of preventative medications (statins and anti-hypertensives) are identified and treated.
“The success of statins and antihypertensive drugs in reducing high cholesterol and high blood pressure has been proven in several randomised controlled trials, and incorporated in standard NHS practice. It is estimated that statins alone save 7,000 lives in the UK every year.”
And the British Heart Foundation agreed that some people over 80 would still benefit from taking the drugs. A spokeswoman said: “Interestingly, there is still evidence suggesting these pills can be beneficial for some people of this age. Further research would help us understand the pros and cons better so in the interim a cautious approach in prescribing these drugs for the elderly is required.”
by Pat Hagan