(Over) Prescribing for the Masses?

Prevention, they say, is better than cure. Public health strategies have focussed on the provision of safe drinking water, safe sewage disposal and mass vaccination. These have greatly reduced death and illness from infectious diseases.

Preventative strategies are now being taken further; your GP will ask ‘screening’ questions, and you might get an invitation for a mammogram or for a bowel cancer check. We’ve all heard about the need to eat five portions of veggies a day (unless you are Greek, when it’s nine portions), exercise, lay off the cigs and be moderate with the booze (killjoys!). (And lots of sex—or at least ejaculation—throughout life distinctly reduces the risk of prostate cancer, but, strangely, this isn’t often mentioned.) But now, should we treat the population for what might be called the natural progression of ageing? As we age, our chances of having raised blood pressure and raised cholesterol do seem to increase and thereby influence our risk of cardiovascular disease, the number one cause of death and morbidity.

While there are vigorous proponents advocating the treatment of asymptomatic problems, people who are almost evangelists in their arguments, people saying that all over, say, 50, should be on a cocktail of drugs—almost whether they need them or notother voices are much more cautious.

The New Scientist published an article about this recently, asking whether mass preventative pill taking was justified. The New Scientist has recognised that medicine, like economics, is often a very political subject. I’m going to concentrate here on cardiovascular disease, specifically high blood pressure and high cholesterol.

High blood pressure (hypertension)

Blood pressure (BP) gradually rises as we age, how much this is ‘functional’ and how much is pathological is uncertain. A high BP is associated with heart attacks and strokes, and with kidney failure.

So, what should a patient’s blood pressure ideally be? Well, a modest rise doesn’t seem to be that harmful, but a big rise is. And treatment of this has aimed at a reduction to a ’safe’ level. However, the ‘goalposts’ keep moving, and what yesterday was an acceptable if raised BP is today seen as too high.

There are several classes or types of pill for raised BP. Some, diuretics, aim to make you pee out ‘excess’ fluids and salts; others act more directly on the blood vessels, particularly the arterioles, involved in the regulation of BP.

High cholesterol (hypercholesterolaemia)

The cholesterol in our bodies comes from fatty food that we eat, but also from our own manufacture. So, even completely omitting cholesterol from our diet won’t eliminate it in the blood; indeed, some level of cholesterol is necessary for proper cellular function. Cholesterol can be deposited in our arteries as ‘plaques’; it there is a clot (a thrombus) on these, the artery can be blocked, leading to a heart attack or an apoplectic stroke.

Statins are a group of drugs which lower blood cholesterol, and also give a better balance between the ‘good’ and ‘bad’ varieties. It’s clear, that if you have had a heart attack, and have raised cholesterol, that treatment with a statin reduces your risk of a further attack. It might seem sensible to say that even if you haven’t had a heart attack, and have no symptoms, but do have raised cholesterol, then treatment will reduce your future risk of a heart attack. This is the nub of the argument for prescribing statins to ‘healthy’ people. However, the results of trials aren’t so clear cut; often, recommendations seem to come down to a matter of ‘belief’ in the efficacy or otherwise of statins. The decision to start statins may depend on your age; perhaps if you are young, but with a very high cholesterol you should have treatment; but if you are an otherwise asymptomatic nonagenarian, is it really sensible?

Like blood pressure, the ‘goalposts’ for ideal cholesterol levels in the blood do get altered from time to time; and always downwards.

Aspirin

Aspirin was originally the German company Bayer’s trade name for acetylsalicylic acid. It’s been known from antiquity as a remedy for headache. Originally prepared from the bark of the willow (Salix species, hence the chemical name) an identical molecule is now made synthetically. The Bayer company didn’t think much of it initially, preferring to direct their efforts at another vegetable extract, heroin. Aspirin is anti-inflammatory, and interferes with blood coagulation by an action on platelets. It has been associated with significant stomach (gastric) bleeds; a much lower dose is used as to prevent a blood clot forming on a plaque.

Risk

There are algorithms which can calculate your risk of a heart attack given your age, weight, BP etc. It used to be that a risk greater than 20% was an indication for treatment; now, the level is 10% (and lower in the US). However, determining whether it is sensible to take treatment can be very difficult. Often, the effects of drugs are  given as ‘risk reduction’. Now, a claim that a drug reduces your chance of death by 50% sounds impressive; this is relative risk reduction. But if we look closer, we might find that if your risk is, say 2%, and that treatment reduces it to 1% you might well wonder if it’s worth it; this is absolute risk reduction. And you might find this all expressed rather differently; treatment might have to be given to, say, 10,000 people to save one or two lives; this is the number needed to treat. It’s no surprise that which statistic you use can be determined by your viewpoint; a drug company may use relative risk; an epidemiologist, the number needed to treat.

Side Effects

Side effects are things that drugs do that we don’t want them to. If you read the information leaflet with your pills, you’ll see a long list of these side effects. Any medical student knows that all drugs can cause gastrointestinal upsets and rashes; some side effects are more specific. And any cynic will tell you that if a drug doesn’t have side effects, then it doesn’t have any effects at all.

During clinical trials of drugs, patients are closely monitored for unexpected effects. When drugs come to market, doctors are advised to report any ‘adverse’ effects; how many do isn’t certain. So, the frequency of side effects is a bit uncertain, and is anecdotally higher than described. Calcium channel blockers, used in BP treatment, are known to cause leg swelling or ‘oedema’. I asked a senior colleague about this, and he reckoned that perhaps 25% of his female patients had this problem, and not liking thick ankles, stopped the drug; this is a far higher proportion than official statistics suggest. A very commonly prescribed treatment, statins, seem to have a much higher incidence of depression and insomnia than reported, to the extent that many patients stop them after a few years. (During a trial of the BP treatment sildenafil, it was found not to be very effective; but male patients frequently reported a strange though welcome side effect.  And, after ‘rebranding’, voila! a single factory in Cork struggled to meet world demand for Viagra.)

Grapefruit

Grapefruit is a natural hybrid between an orange an a pomelo. It interacts with at least 85 drugs; some interactions are serious, potentially fatal. The patient advice leaflets on statins and calcium channel blockers have warnings about grapefruit juice.

What should I do?

Well, a facile answer begins with where you are now. More exercise, less fags, less booze, more greens is a good start. But beyond that: well, that’s not so easy for any individual. In part it depends on your ‘risk factors’ and how much you can reduce them, if you are willing; it depends on your approach to ‘authority’—do you do as your are told, or are you argumentative, questioning the reasoning behind the decisions? Are you willing or unwilling to accept a certain level of ‘risk’ in a population, not knowing whether the risk will apply to you? Trying to work out the individual benefits versus risks versus side effects for any pill isn’t so simple, and much more complicated when it’s suggested you might need several, typically something to lower your BP, a statin and aspirin—for starters.

Note: the above is background information not medical advice, for which you should attend your general practitioner or an appropriate specialist.

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  • Jag

    “And lots of sex—or at least ejaculation—throughout life distinctly reduces the risk of prostate cancer, but, strangely, this isn’t often mentioned”

    Funny how you never hear of priests dying from prostate cancer (you used to have “Monks Disease” but you never hear about that these days). Divine intervention, no doubt.

    BTW, wonderful extension to Slugger’s appeal to have a health section, particularly given the very unhealthy lifestyle of themmuns and ussuns in this place.

  • whatif1984true

    Lots of info. Thank you. Is there anywhere that specifies which tests you should normally be having at different ages and how often they should then be repeated. Do Doctors now have computer reports which flag up patients who are overdue specific tests.
    I appreciate these are not urgent, but if good practice is to have a prostrate cancer test at 60 and at 62 you haven’t had one, how does one know?

  • ConallBoyle

    Send your poo in the post when asked! It’s the screening test for bowel cancer for women and men aged 60-70 in Ireland (both parts), or 60-75 in mainland UK. Don’t Irish lives 70-75 matter?

    And I can testify it works! Aged 72 in Wales, was caught ‘on-screen’ with stage 1 bowel cancer. The op. has been ‘a complete success’ says my specialist. Do it, I beseech ye! Send your poo in the post. This is one form of screening that really works!

    But…..the sad thing is that: Half of those asked chuck the screening kit in the bin.
    And: It should be applied to all those between 50 (not 60) and 75. (Yes, austerity strikes again)

  • rapunsell

    Good article. I was diagnosed with essential hypertension about 12 years ago – it was a great shock at the time – I was early 30s. I developed serious anxiety about it – the thought about lifetime medication terrified me. It needn’t have. Had a brilliant consultant at Belfast City Hospital who identified the very best drug for me with limited side effects – Candesartan Cilexitil – I’ve been on 8mg daily since with blood pressure controlled and have never had any side effects. I’m glad now that my high BP was identified in a routine GP check , it was dangerously high and I was likely headed for a stroke. More recently the cholesterol has been raised too but GP prescribed then reversed the decision for statins as I’ve managed to bring the level down and increase the good cholesterol over a year. I’m a serious exerciser and do activity daily with intensive activity 5 days per week and watch the diet , maybe too much booze on occasion. I think what I’ve learned is the key to controlling some of these problems is discipline – and the levels of discipline required are serious . Discipline to take the medication daily – I think there are studies that show the BP medication is even more effective if taken at night instead of the morning but that needs to be discussed with GP, discipline around diet and discipline around exercise. I think the public health messages and provision around smoking, diet and exercise aren’t ambitious enough. To get fit, lose weight and control factors like BP and cholesterol takes a serious , long term and life changing commitment. People often need support to do that. I’m lucky in that I love exercise being stuck in a desk job and I’ve managed to build a routine in and around work and family life so much that it becomes second nature. I’d encourage people in their 30s and 40s to get their Bp and cholesterol checked and honestly think about their diet and alcohol consumption. I’ve a young family , I want to see them grow up and have families of their own and be fit enough in the future to do the things I like doing. Whats not to like about that ambition

  • Korhomme

    The NHS website has several articles about screening in general, for example this one:

    http://www.nhs.uk/Livewell/Screening/Pages/Checks30to64.aspx

  • Korhomme

    You are quite right about the commitment. For some people, even a strict diet may not bring their cholesterol to a ‘good’ level.

    Dr Michael Mosley has presented several TV programmes about diet—the 5:2 diet, and the varieties of exercise which are available, and which may be most appropriate for people. There are links in this:

    http://en.wikipedia.org/wiki/Michael_Mosley_%28broadcaster%29

  • Korhomme

    It was one of Slugger’s editors who invited me here, and who suggested this particular topic.

    For those wondering, ‘Monks Disease’ is prostatitis, an inflammation of the prostate, said to be due to ‘excessive retention of vital bodily fluids’.

  • Korhomme

    I am delighted for you!

    BTW, there is an article on rectal bleeding and bowel cancer screening in today’s News Letter, though it doesn’t seem to be on-line.

  • Jag

    Judging by the survival of the Daily Express and its screaming (and often flip flopping) front page headlines on what’s good and bad for your health, it would be popular to see some regular contributions from you Korhomme. After all, health is not only the government department now facing the greatest bugget cuts, but health issues don’t recognise our religious divide, and given 60-70% of us in NI are overweight (and even the PSNI can’t get recruits because women in particular lack basic fitness levels), health, personal and institutional, could benefit from greater debate.

  • Jag

    So true about daily and life-long commitment – with our sedentary lifestyles and abundance of cheap nutritionally-poor foods (not to mention the overwhelming marketing of such foods), we’ve never needed commitment more.

  • whatif1984true

    Thank you. MEN. Recent stats from USA incidence of Prostrate Cancer in All men 168cases per 100,000 – death = 27.9/100,000.
    Breast Cancer in All Women 127.8/100,000 death = 25.5/100,000.
    On the NHS website no timetabled checks for men at various ages despite a higher death rate and also the probability that prostrate cancer can often present no symptoms.
    Breast cancer screening is every 3 years from about 50 -70 years of age.

  • Korhomme

    The rates of both breast and prostate cancer increase with age, occasional tragedies in young women as reported in the tabloids notwithstanding. We were taught that prostate cancer is almost inevitable with age; perhaps 90% of men in their nineties had the disease. Many of them had no problems. On the other hand, prostate cancer can be very ‘aggressive’ in some (younger) men. Disease screening is also subject to a cost/benefit analysis.

  • Korhomme

    I’d have thought that the Daily Express, Daily Mail or Sun were not the most reliable sources of health information. Yet what they report is often based on press releases provided to them, and taken up by journalists with little or no understanding of health care; their sub-editors are good at ‘screaming’ headlines.

    But you are certainly correct; people in general should take much greater responsibility for their own health and welfare whenever possible.

  • whatif1984true

    With improved longevity it seems we will now more frequently die of cancer. Is the age at which prostrate cancer arises very advanced and insignificant for 55/60/65 year olds?

    You appear to suggest that the ‘powers that be’ reckon that the absence of screening in men is good value. How is this reconciled to more men dying of prostrate cancer than women dying of breast cancer.
    I presume that cost/benefit analysis is ‘age’ blind.
    Thank you.

  • rapunsell

    it pains me that smoking is still so prevalent especially in disadvantaged communities. Interesting to note that a shop selling legal highs is burned out whereas the shops selling tobacco and their manufacturers get away with murder almost literally. we have to think of new ways to get people to stop smoking and start taking part in healthy and enjoyable activities. what are the profits to be made from selling cigarettes by a local shop? Why should we not lower VAT or incentivise shops esp corner shops in neighbourhoods not to sell tobacco products

  • rapunsell

    I tried the 5:2 year before last, I’m not really overweight but wanted to trim down a bit for sport. Yeah it worked but it was very very hard to do. Now to be honest I eat anything I want – but I don’t want or eat crisps or biscuits or processed food anyway and focus on nuts, fruit and veg etc. For me the key is lots of exercise and I’d say im fanatical about that – but it beats being fanatical about going to the pub

  • Granni Trixie

    From what I’ve read genetics plays a significant part in who is vulnerable to high colhestrol. I noted this when a skinny relative had higher level than fatties I know (sorry if this is politically imcorrect). He simply could not bring it down with exercise so required statins.

    BTW, I read about not taking grapefruit in the teeny,tiny print side the box and it did strike me that most normal people wouldn’t bother reading that. Now you say it could be fatal!

  • Korhomme

    Rather than dying of cancer, there’s a view that people might die with cancer.

    I didn’t mean to suggest that the absence of screening in some age groups represents ‘good value’, and I’m not wholly certain why only certain age groups are targeted.

    In general, most cancers increase in frequency as we age—this is certainly true of breast cancer.

    To give more specific answers to your questions I’d need to do some more research.

  • aquifer

    How about prescribing some walks? Would Translink fund a leaflet setting out the nice walks that the over 60’s can get to for free? The Docs would be better handing those out than many pills. Better do it quick before the Tories remove free travel.

  • notimetoshine

    My 51 year old father died just over a month ago from a massive heart attack. He didn’t drink or smoke, he wasn’t overweight, had extremely healthy diet; no red meat, lots of grains nuts and green vegetables, played football, was a mountain biker and a fell runner. The man wouldn’t even eat cream, bisucits or sweets for god sake. He took all the health food supplements, aspirin a day and still dropped dead while cycling. He did everything right yet died from what could be considered to be a lifestyle disease. He had heart attack and coronary thrombosis with an atheroma.

    I can only deduce from this and my somewhat amateur research that there must be a serious genetic riskcomponent to these things. If you do everything right that might still not be enough.

  • Deke Thornton

    Sorry for your loss, but family history trumps all other cards. I know a family that lost 4 sons/brothers in their early 50’s to heart attacks within 2 years. Their father suffered the same fate. That’s not to say lifestyle isn’t a factor, just not the main one. Genes ‘R’ Us. The (often contradictory) ‘advice’ given in the tabloids is worthless. The Daily Mail ran a headline that more housework can help add 20 years to women’s lifespan. (They never mentioned men and housework for some reason.)

  • Korhomme

    That’s a sad story, the sort of thing that seems so unnecessary.

    Most illnesses have ‘environmental’ and ‘genetic’ components. Not just, say clean water and vaccination, but our ‘lifestyle’ and all that means. And the genes can make us more of less resistant to illness. We can try to improve our environment, but dealing with our genes is (mostly) beyond us at present.

  • Starviking

    It’s post 40 in Japan. Whether that is a good thing or not is a different matter.

  • whatif1984true

    Thank you. I wondered if the resource was going to the more vocal as opposed to the most needy.
    Politics over clinical advice. (Cut back Breast screening to give more screening to men-cannot see this happen ever.)
    Sorry I wasn’t targeting your opinion but that of the people who have not prioritised Prostate screening.
    From the Prostrate Cancer Foundation :-
    “In fact, a man is 35% more likely to be diagnosed with prostate cancer than a woman is to be diagnosed with breast cancer.
    “As men increase in age, the risk increases exponentially. 1 in 10,000 under age 40 will be diagnosed, the rate shoots up to 1 in 38 for ages 40 to 59, and 1 in 14 for ages 60 to 69.”

  • Jag

    I’m sorry for your loss, such an important figure in anyone’s life and just a month ago.

    I’m not sure they’re an expert, but someone I know who’s had major health problems for most of their adult life, thankfully all covered on private health insurance, said something to me that resonated. That medical conditions come down to three factors – lifestyle, genetics and luck.

    The recent US study on cancer seems to highlight “luck” as the pivotal component in developing cancer (apart from smoking which would come under “lifestyle”).

    Your Dad’s healthy lifestyle ultimately didn’t prevent an early death, but without it, the tragedy may have taken place a long time ago. And that’s probably the value of advice on lifestyle.

  • Jag

    Korhomme, obviously you don’t know the individual above, but in general terms, would that sort of condition have been picked up in any sort of routine screening?

  • Korhomme

    Jag, patients should be asked about their family history, that is, what close relatives suffered from or died from. If there is a history of heart attacks at a young age, this is a significant marker. (See Deke Thornton’s comment.)

    Otherwise, the patient’s history, family history, physical examination, ECG and blood tests could all be normal; while this reduces the overall risk of a heart attack significantly, it doesn’t rule it out completely. (Test results can be in the ‘normal’ range for a population, but abnormal for an individual, and vice-versa. This is just the (mathematical) way such statistical ranges of data are presented.)

    I’d guess that in the future genone sequencing would be useful; this could add a further measure to identify people at genetic risk of disease. But such testing raises difficult issues. For example, how easy will it be to get life assurance? Do you really want to know that you have a high risk of developing a disease which is untreatable?