How docs can manage our aging populace's constellations of meds

Headlines warned recently that a commonly prescribed class of antacid medication was found to have more than doubled the typical risk for gastric cancer among patients who carry the Helicobacter pylori stomach bacteria.

The negative finding focused on proton pump inhibitors (PPIs, such as Prevacid and Prilosec).  It was meaningful for Doug Paauw, an internal medicine specialist who has written about PPIs’ risk.

“This is just another in the litany of concerns about PPIs that makes us push to get people off them who don’t need them. The risk of PPI that are significant and we have to always continue to reassess that risk for patients and make sure they’re aware of it,” he said.

Physicians take note of research findings like this, particularly those involving common prescriptions like antacids, and especially as they accumulate.

“The more noise there is about certain drugs, the more worried we get – even though retrospective studies don’t indicate causality,” Paauw said. “With PPIs, there are concerns about C. diff., bone fractures, vitamin B deficiency, gastric cancer, acute kidney injury, dementia. When you accumulate five or six concerns like that, even if only half are real, that’s risk to my patient.”

The conversation morphed into one about how doctors manage the shifting constellations of drugs in our aging populace.  What’s the physician’s responsibility to ensure that a patient’s meds should be continued, changed, or ended? 

Paauw said some doctors hesitate to take patients off potentially risk-creating drugs, like PPIs, for fear of “rocking the boat. If a patient is doing well, we don’t like to change what we’re doing.”

Moreover, physicians are graded on how well they adhere to “optimal treatment” guidelines established by Medicare. These guidelines dictate which drugs, for common health conditions, are likeliest to result in a good patient outcome. But they do so in isolation, without regard to which other meds a patient may take.

“And payments to physicians are now based on whether they box-check the guidelines. So if you use great judgment and think, ‘It’s not safe for my 93-year-old patient to be on all these guideline meds,’ your rating is dropped,” Paauw said. “You are considered a worse doctor. That’s the absurdity of where we’ve gone. It takes away rationality and individual thought and the sense of doing the right thing.”

Nevertheless, a physician’s duty, he clarified, is to talk with the patient and, every year, review every medication: Are you still getting benefit? What is your risk? Should we continue it?

Because a clinician sees dozens of patients in a day and then logs all those visit details into electronic medical records, it’s not realistic to expect medication discussions to happen at every visit, Paauw added. He asks patients to schedule an appointment focused solely on medications.

“I really appreciate my patients who say, “Doc, do I still need to be on all these drugs?” But it’s really the physicians’ responsibility to keep patients on safe medication list. We need to be cognizant of that. I think some useful advice is this: Every time you start a new drug, think about what other drug you might stop.”

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