Rod’s dodgy drugs top-ten countdown!

There are plenty of good medicines out there and likely huge numbers of people benefit – for example, I am almost certain, without my dad receiving an early prescription for Simvastatin and Lisinopril (thanks Dr Thompson), his life would have been considerably shorter.

My top-ten is quite specific, it is for the select group of people who come to me, often self-selected by their longevity, accompanied by a variety of ills associated with ageing, most commonly dementia or some form of cognitive impairment, but, also, immobility, reduced ability to care for themselves – not getting out, multiple organ failure – heart, kidney. These are people not in their prime, but, equally capable of living full, meaningful lives with support, with a helping-hand from friends, family and carers, who have the full array of hopes, fears and aspirations that any of us share at any age.

So, let me begin.

Betahistine, also known as Serc. This drug is officially classified as a vestibular sedative and can be used to treat Meniere’s disease, vertigo and other forms of dizziness associated with diseases of the middle-ear. The problem is however that it often doesn’t work and is dominated by side effects – stomach upset, nausea, vomiting (yes, the symptoms of vertigo) and, more times than I care to mention, it is prescribed to treat dizziness which is actually caused either by other pathological processes, that is, postural hypotension associated with ageing, diabetes or Parkinson’s, but which are not diagnosed in primary care because the doctor or nurse-practitioner haven’t taken an adequately detailed history or measured the patient’s blood pressure with them lying down, then standing-up. Usually always stop.

9. AdCal, other names are Calcichew, Calcium and Vitamin D combination. This medicine is often used in combination with another class of drugs – Bisphosphonates, both of which work in combination to improve bone-heath, this is, reduce, treat or prevent the process of osteoporosis and its associated problems of broken hips, pain and immobility. I have nothing fundamentally against these drugs, it is just that often people don’t know when to call time on them. Their advantage, by and large, is that you don’t have to swallow them, therefore the challenge of them sticking in the throat is lessened. Yet, commonly these tablets (they are quite big and usually chalky-white), become something that an older person sucks or chews, taking their time, to the extent that their breakfast is spoiled and if, prescribed twice a day, it is how they go to sleep, sooking on chalkiness, which by the time someone is very frail and immobile likely adds little to their bone health, they are often by this time unable to take the bisphosphonate which is meant to be consumed sitting or standing upright followed by a pint of water – to prevent damage to the gullet. Sigh. Often stop.

Ibuprofen – well, Non-steroidal anti-inflammatory drugs (NSAID’s) in general. Others include Naproxen, Diclofenac, Aspirin – these can be tremendous medicines – indeed, for the person who was in pain and is now not, life-transforming. Yet, they come at a cost, their side-effect profile is amongst the highest of this list – allergy, renal failure, fluid retention, stomach ulcers are amongst the commonest and most significant. Recently we have learned that NSAID’s in general can increase the risk of heart attack and stroke amongst certain groups of high-risk people. This is a class of drugs that warrants serious consideration and discussion. Are the benefits greater than the risks, can the patient manage on the minimum dose; are they actually relieving any pain or inflammation? Usually stop.

7. Cinnarizine – this is another vestibular sedative like Betahistine, with similar indications and uses. It is equally ineffective, although with the added risk that it is mildly sedative, thus contributing to an increased risk of falls in older people as well as having anti-cholinergic effects which contribute to confusion and disorientation in susceptible groups. More on this below. Nearly always stop.

Codeine – I have fallen-out of favour with codeine over the years; it used to be something I would prescribe for pain; the more I learn, the more I see that it is not a great pain-killer, it significantly contributes to nausea, constipation (and associated feelings of lethargy, urine infection and incontinence in older people) and can make people more confused – it is a relation of morphine. For these reasons, I usually consider whether the patient is receiving any benefit and or whether something better might be appropriate. Usually stop.

Amitriptyline – we are now entering the top five dodgy drugs and the competition is hotting-up. This medicine is an old-fashioned anti-depressant, taken in small doses to help pain caused by nerve injury or damage – we call this neuropathic; it aids sleep and in higher doses helps treat depression. It has been around for many years and, it deadly in overdose. It is the lower doses that often attract my attention, particularly in people who have dementia, where it almost always, because of the anti-cholinergic properties mentioned in relation to Cinnarizine at number 7, can make symptoms of confusion and disorientation worse; it can also lead to urinary retention and blurred vision. Let’s put it this way, if you ask the patient and they tell you that until they received the Amitriptyline their lives were dominated by shooting pain or numbness in their feet from diabetes, pause; if not, consider a dose reduction with a view to stopping. You have to be much more careful at higher doses used to treat mood disorders, usually requiring specialist help. In low doses in those with dementia or delirium almost always stop.

Haloperidol – this is an early anti-psychotic drug. Routinely used in palliative care as it is effective at relieving symptoms of nausea, it can also help with frightening hallucinations with occasionally accompany terminal delirium. It isn’t as bad as some of the drugs I find patients still prescribed such as Chlorpromazine – which are usually because they haven’t had a drug review in 50 years. These drugs like lots on this list have anti-cholinergic properties, this is, they antagonise the effect of Acetyl-Choline (stop it working) – this important neuro-transmitter is central to the disease processes associated with Alzheimer’s and other dementias. Indeed, some of the anti-dementia drugs seek to raise levels of Acetyl-Choline in the brain, the opposite of these medicines.

So, Haloperidol is an old-fashioned drug, it comes with significant side-effects and when used to treat symptoms of anxiety and distress in those who have delirium or dementia is ineffective (despite what NICE says folk), long-term use significantly increases the risk of stroke and heart attack – premature death in general for those living with dementia, it contributes to increasing falls, constipation, urine retention and can create a Parkinson’s Disease-like state. (As if everything else wasn’t bad enough). I always stop.

Nifedipine – I am changing tack a little with this drug as I have been on a theme of tablets that predominantly affect the central-nervous system (i.e. the brain). Nifedipine is in the class called calcium-channel blockers and is usually prescribed to treat high blood pressure and sometimes angina. Other similar medicines are Amlodipine and Lercanidipine. It isn’t necessarily a bad drug and many millions of people have no doubt lived longer than they would otherwise thanks to its effect on blood pressure. It is when a person is older, perhaps frailer and with their deteriorating self and an associated natural drop in blood pressure that Nifedipine can become toxic, often leading to falls because of postural hypotension – the blood pressure system failure, where inadequate blood flows to the brain leading to dizziness, falls and sometimes collapse. A great number of older people I see who have fallen and are prescribed this drug have this disorder which has been missed or un-diagnosed. It also causes puffy ankles. As it doesn’t contribute to confusion, it is a bit of a wolf in sheep’s clothing. Often stop.

Oxybutinin – the competition is becoming fierce. Who will claim the number-one spot? This is one of my most hated medicines. It is principally used to treat what is called urge incontinence – this is incontinence associated with a sensitive bladder. It works, but today, in 2018, there are many more effective medicines that don’t carry as many side effects and work just as well. Everyone prescribed this drug has a dry mouth. Having a dry mouth is miserable. It affects flavour and general wellbeing. It wakes you from sleep, that is, if you aren’t already disturbed by the associated nightmares and disorientation which are other side-effects. It is a prime culprit in urinary retention – the inability to pee, necessitating a urinary catheter, with all the associated problems – dignity, infection, immobility. It is bad, bad, bad. I always stop this medicine.

Gabapentin – this drug was originally used as a treatment for epilepsy, recently it has become more often used as a treatment for pain, specifically nerve-associated or neuropathic pain. It is also a drug of abuse. Called ‘Gaba’ on the street, Doncaster at one point was the national capital for illicit trade. I have no idea why this should have been the case, and I believe, with stricter prescribing it is now less of an issue, but still beloved of those short of cash with a granny they can scam for the odd prescription.

Here are a list of the common side effects of Gabapentin:

Abdominal pain; abnormal reflexes; abnormal thoughts; acne; amnesia; anorexia; anxiety; arthralgia; ataxia; confusion;

constipation; convulsions; cough; depression; diarrhoea; dizziness; drowsiness; dry mouth; dry throat; dyspepsia; dyspnoea; emotional lability; fever; flatulence; flu syndrome; gingivitis; headache; hostility; hypertension; impotence; increased appetite; insomnia; leucopenia; malaise; movement disorders; myalgia; nausea; nervousness; nystagmus; oedema; paraesthesia;

pharyngitis (in adults); pruritus; rash; rhinitis; speech disorder; tremor; twitching; vasodilatation; vertigo; visual disturbances; vomiting; weight gain

In other words, it can pretty much cause the side-effects of all the medicines I have already listed in the top ten above. That is some feat!

Yes, the drug can be used for treating epilepsy, and, in that case, leave well alone, yet, as a medicine for those people who have chronic pain, who perhaps don’t have any underlying identifiable pathology – yes, people with functional disease, it can make things worse; when reassurance, socialisation and a friendly ear are required, it is a poor substitute. Some of its symptoms mimic dementia – indeed, some patients think they have dementia before discovering their forgetfulness, mood and personality change are caused by the drug instead. Given its anti-epilepsy properties, more care must be taken in stopping Gabapentin than other drugs, yet this can be done successfully over a number of weeks with dramatic effects to the wellbeing of the person affected. This is an always stop in my group of patients unless there is some other over-riding, overwhelming indication.

So, here are my top ten.

I suspect those who know me could have guessed most. Because there are only ten, I have had to leave-out some of my other favourites – Tramadol being the most pernicious, although I seem to see less of that than a few years ago. Perhaps prescribing habits are changing.

As an end-note – this top-ten is for information purposes only. Never stop taking a prescribed medicine unless this has been discussed with your GP or hospital specialist. Suddenly stopping a medicine, even one which is potentially harmful can had significant consequences for your health such as seizures and horrible withdrawal effects.