Is this proof pill-popping Britain should stop taking the tablets?11/12/2018
Is this proof pill-popping Britain should stop taking the tablets? In the first of a two-part investigation, we reveal how medication is being massively over-prescribed — and may do more harm than good…
- In 2017, the NHS prescribed 1.1 billion items — double the number a decade ago
- As many as 20 prescriptions are now written per head of population each year
- Meanwhile, more than half of over-65s take five or more prescription pills a day
We are taking more pills than ever — and the trend shows no sign of abating. Last year, the NHS prescribed more than 1.1 billion items — almost double the number ten years ago.
And that figure doesn’t include medication dispensed in hospitals.
As many as 20 prescriptions are now written per head of population each year — a rise of a third in just a decade, the Mail reported last week.
Meanwhile, more than half of over-65s take five or more different prescription pills a day. Some take more than 20.
Are you taking too much? As many as 20 prescriptions are now written per head of population each year — a rise of a third in just a decade, the Mail reported last week
Yet many of the most commonly prescribed drugs are controversial and have been linked to risks that some experts say outweigh the benefits.
Take cholesterol-lowering statins. At more than 37 million prescriptions a year, atorvastatin is the most prescribed medicine in the UK — yet a study published last week in the Annals of Internal Medicine concluded too many healthy older patients take statins.
Those who have a 10 per cent risk of cardiovascular disease over the next ten years are prescribed the drugs. But, according to researchers, the benefits outweigh the risks only in those with a 14 to 22 per cent risk.
Last weekend, Health Secretary Matt Hancock revealed he had ordered a review into our reliance on prescription drugs, warning that a ‘small army of people’ from drug companies was pushing their use. He wants GPs to do more ‘social prescribing’ — such as joining walking groups.
In the first of a unique two-part prescription pill audit, Good Health asked the experts for an update on some of the most commonly prescribed drugs in the UK.
Today, Jo Waters looks at some of the big ‘blockbuster’ pills for heart conditions and indigestion. Next week, she examines painkillers.
ASPIRIN’S HIDDEN COST
Fact: Aspirin can damage the protective mucus lining of the stomach, allowing ulcers to form, and cause pre-existing ulcers to bleed, so it has fallen from favour as a painkiller
Twenty years ago, aspirin was the new great hope for heart problems: not only was it a painkiller, but it could also thin your blood (by reducing the clumping of blood platelets) and reduce your risk of cancer, including bowel cancer.
Indeed, it continues to be the first-line treatment for those who have had a heart attack or stroke to prevent further blood clots, and a preventative treatment for those at increased risk of such an event.
It has long been known that aspirin can damage the protective mucus lining of the stomach, allowing ulcers to form, and cause pre-existing ulcers to bleed, so it has fallen from favour as a painkiller.
But a new trial published in October in the New England Journal of Medicine has now challenged the idea that low-dose aspirin may prevent heart attacks or strokes in healthy older people.
The study of 19,000 people aged over 70 showed low-dose aspirin (100mg) taken daily does not significantly reduce the risk of a first heart attack or stroke, or improve disability-free survival (defined as being free of dementia or physical disability).
Furthermore, it showed an increase in the number of cases of serious bleeding among the aspirin-takers (3.8 per cent) compared with those taking a placebo pill (2.8 per cent).
‘Millions of healthy older people may be taking low-dose aspirin unnecessarily,’ the lead investigator, Professor John McNeil, of Monash University, commented.
WHAT IT MEANS FOR YOU
Aspirin is still thought to benefit those who have already had a heart attack, stroke or angina, says Professor Peter Rothwell, director of the Centre for Prevention of Stroke and Dementia at the University of Oxford. ‘There is also evidence that aspirin reduces the risk of heart attacks, strokes and cancer in people in their 50s and 60s who have not had a heart attack or stroke, but the benefits are relatively small.
‘The new study, however, cautions against healthy individuals starting aspirin after the age of 70,’ says Professor Rothwell.
‘The benefits for cancer prevention might be larger in people with a family history of colorectal cancer, or who have had a bowel polyp or cancer, but the exact balance of risk and benefit isn’t known.
‘If you’re on aspirin, don’t stop taking it, but discuss the risks with your GP.’
Sultan Dajani, a community pharmacist from Eastleigh, Hampshire, says older people have a thinner stomach lining, making them more vulnerable to the bleeding aspirin can cause. But ‘these risks can be reduced by taking your tablets with food and taking a PPI’, he says.
ASK IF YOU REALLY NEED TO BE ON STATINS
Did you know? Spanish researchers found that statins were not associated with a reduction in cardiovascular disease or death in healthy people aged over 75
These cholesterol-lowering drugs, which include atorvastatin and simvastatin, are prescribed to at least seven million people in the UK to lower levels of ‘bad’ cholesterol and reduce the risk of heart attack or stroke.
In 2014, the National Institute for Health and Care Excellence (NICE) recommended that everyone with a 10 per cent or higher risk of having a heart attack or stroke in the next ten years should be prescribed 20mg a day; those with established heart disease should start on 80mg a day.
In practice, this means almost all men over 60 and all women over 75 qualify for statins prescriptions — in total, 11.8 million people, according to U.S. research published in the Journal of British General Practice in 2017.
And it’s not just older people. More than a third of 30 to 84-year-olds exceeded the thresholds, 9.8 million of them healthy and with no history of heart attacks or strokes, the same study found.
Some GPs are concerned about ‘medicalising’ so many people, especially when some complain of side-effects such as muscle pain and mental fogginess (although many experts claim side-effects are rare).
A review of 300 trials carried out since 1990 and published in The Lancet in 2016 concluded that prescribing statins to people who hadn’t previously had a heart attack or stroke prevented 80,000 heart attacks and strokes a year in the UK, and that the benefits far outweighed any harm from side-effects.
However, critics such as Dr Malcom Kendrick, a GP in Cumbria and author of A Statin Nation: Damaging Millions In A Brave New Post-Health World, maintains their benefits have been overhyped and the side-effects are underestimated.
‘There has not been one positive statin randomised controlled trial since 2005 — all the studies are just “data dredges” going back over old research and looking for positive associations,’ he says.
An analysis by Dr Kendrick of the landmark 2002 Heart Protection Study which concluded that taking statins saves 50,000 lives a year revealed that ‘if you took statins for five years after having a heart attack, it would extend your life by only 4.2 days; and if you were healthy and took a statin for five years it would lengthen your life by 3.1 days.
‘The people saying statins don’t cause many side-effects are not clinicians. They are not seeing people complaining about muscle pain like I am.’
The West of Scotland Coronary Prevention Study found that 25 per cent of people on statins had stopped taking them within five years.
Dr Kendrick said the latest study on statins published in the Annals of Internal Medicine is further proof that they are being overprescribed: ‘Is it worth taking statins? The answer is no — unless you are a man who has had a heart attack or stroke. There are no proven benefits for women at all.’
Professor Sir Nilesh Samani, medical director of the British Heart Foundation, says the evidence is ‘very strong’ that if you have had heart or bypass surgery, or have coronary artery disease (for example, people with angina), statins can reduce future events.
‘There is also good evidence that statins can reduce the risk of heart attacks and strokes in people with risk factors including high blood pressure and high cholesterol.
‘In the general population who have not had heart attacks or don’t have heart disease or risk factors, there is evidence that taking a statin can, over time, reduce the risk of an event by 30 per cent.’
But your age and health are key considerations, suggests a study published in October in The BMJ.
Spanish researchers found that statins were not associated with a reduction in cardiovascular disease or death in healthy people aged over 75. However, there was a benefit for people with type 2 diabetes, reducing death from any cause and cardiovascular disease up to the age of 85.
WHAT IT MEANS FOR YOU
Talk to your GP, especially if you are older and otherwise healthy.
‘Age becomes an important risk factor, but I am not advocating that all older people who are healthy have to take a statin because of their age alone,’ says Professor Samani. ‘A bit more sense must prevail.’
The most common side-effects — muscle aches, insomnia and erectile dysfunction — are very common in the population anyway, he adds. ‘People may hear about statin side-effects, then experience muscle pain or insomnia and think it must be the statins causing it.
‘If patients believe they are experiencing side-effects, they may want to stop the tablets for a while and see if they feel better, or swap to a different statin.’
BLOOD PRESSURE PILL RISK
Concern: Side-effects include a persistent dry cough, flushing and headaches initially, as well as fainting due to lowered blood pressure and fluid build-up around the ankles
Angiotensin-converting enzyme drugs, otherwise known as ACE inhibitors, are used to treat high blood pressure and heart failure. They help widen blood vessels by relaxing the muscles around them.
There are many versions including enalapril, lisinopril, perindopril and ramipril, which is the fourth most commonly prescribed pill in England.
Side-effects include a persistent dry cough, flushing and headaches initially, as well as fainting due to lowered blood pressure and fluid build-up around the ankles.
A study published in October by researchers at McGill University in Canada, found that those who took ACE inhibitors were at a 14 per cent increased risk of lung cancer compared with those who took a different type of blood pressure pill.
The findings were based on data from a million UK patients who took ACE inhibitors between 1995 and 2015.
Professor Nilesh Samani, medical director of the British Heart Foundation, says the results were a ‘surprise’, as ACE inhibitors are generally well tolerated.
‘They are undeniably life-saving,’ he says. ‘One of the limitations of an observational study [looking back at patients’ medical records] like this one is that people may have developed lung cancer for reasons other than taking ACE inhibitors, such as being smokers.
‘Randomised controlled trials have been carried out on ACE inhibitors for 30 years, and to my knowledge no other study has found an association with lung cancer.’
WHAT IT MEANS FOR YOU
Professor Samani says ACE inhibitors are used mainly to treat heart failure and less for high blood pressure these days.
Anyone concerned by the risks (such as smokers) could ask to switch to calcium channel blockers — amlodipine, felodipine and nifedipine — and Angiotensin-2 receptor blockers (ARBs) such as candesartan, irbesartan and losartan.
HEARTBURN PILLS OVERUSED
Proton pump inhibitors (PPIs) help reduce the amount of acid produced by the stomach.
Originally intended to help with serious stomach conditions such as gastric and duodenal ulcers, these days they are commonly prescribed for indigestion and heartburn, and to a lesser extent to counter the gastric side-effects of nonsteroidal painkillers such as ibuprofen and naproxen.
The number of prescriptions for these pills — which include omeprazole and lansoprazole —has soared from 29 million in 2007 to more than 59 million last year, making them some of the most frequently prescribed drugs in the UK.
PPIs were originally licensed to be used for no more than four weeks. However, people stay on them for months or even years.
As PPIs reduce stomach acid, this alters the gut microbiome, allowing harmful bacteria to survive and colonise the gut. One worrying new study by Dr Richard Cunningham, a consultant microbiologist at Derriford Hospital, Plymouth, published earlier this year in the Journal of Hospital Infection, found that taking PPIs increased the risk of antibiotic-resistant infections threefold. These include antibiotic-resistant forms of E.coli and salmonella.
Antibiotic-resistant infections can progress to life-threatening conditions such as sepsis.
‘Some bacteria, such as salmonella, may cause symptoms straightaway, such as a bout of food poisoning,’ says Dr Cunningham. ‘But others, such as E.coli, won’t cause problems immediately living in your gut —then six months later, if they travel to the bladder or get into the bloodstream, they can cause infections which may be hard to treat because the antibiotics won’t work against them. The delay can be fatal for some people.’
These bacteria can also be passed on to people living in the same household.
AND HERE’S WHAT THEY COST THE NHS…
(To lower cholesterol)
Levothyroxine Sodium £87m
(For underactive thyroid)
(Proton pump inhibitor to reduce production of stomach acid)
(ACE inhibitor for high blood pressure and heart failure)
(For high blood pressure and heart disease)
(To lower cholesterol)
(PPI for stomach acid)
(A form of vitamin D)
Bisoprolol Fumarate £21m
(For heart disease)
‘In the past, we identified travel to South-East Asia or the U.S. as a risk factor for infection with antibiotic-resistant bacteria — and while that is still the case, PPIs are now risk factors too. A lot of prescribers aren’t aware of this.’
Dr Cunningham says that between 5 and 8 per cent of hospital inpatients have already been colonised by antibiotic-resistant bacteria before they come into hospital.
‘The problem is that if someone does develop an antibiotic- resistant infection months after starting on PPIs, doctors won’t necessarily make the link between the two,’ he says.
An earlier study also linked PPIs with an increased risk of contracting the hospital superbug Clostridium difficile.
But the risks may go beyond infections. A study published this year in the journal BMJ Open linked PPIs to an increased risk of death from all causes compared with those who took H2 blocker stomach acid drugs (these reduce stomach acid too, but not so dramatically).
An Icelandic study published this year suggested that the risk of bone fracture was 30 per cent higher in people taking PPIs, possibly because they may affect absorption of vitamin D, magnesium and calcium, which are needed for strong bones.
WHAT IT MEANS FOR YOU
Check with your doctor or pharmacist whether you should still be on PPIs. Dr Cunningham says PPIs are good drugs if they are used for the right patients for the correct amount of time, including patients with gastric ulcers or those on other medication that irritates the stomach.
‘Somehow they have become the default drug for anyone with indigestion or heartburn,’ he says. ‘Really they should be reserved for more serious problems such as gastric ulcers and duodenal ulcers.’
Studies — including one from King’s College London as long ago as 2008 — estimate that between 53 and 69 per cent of PPI prescriptions are inappropriately being given for indigestion and heartburn.
‘My advice would be to ask your GP or pharmacist for a medication review to check whether you still need to be on a PPI,’ says Dr Cunningham.
‘It may be that you can be swapped on to H2 antagonists, which reduce stomach acid but not so drastically.
‘PPIs are now available over the counter at a lower dose, so the worry is that people can carry on taking them indefinitely without ever seeing a doctor.’
Dr Mike Dixon, a GP in Devon, adds that when people come off PPIs they get an excessive production of stomach acid and feel they need to restart them. ‘The problem can be avoided if the dose is reduced gradually rather than stopping overnight,’ he says.
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