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Risky Medications Popular in N.H. Medicare

Should you be taking those pills?

The most common medications dispensed to Medicare patients in New Hampshire include one drug that doctors and pharmacists say should be used only for short periods, because it may harm patients over the long term. Other even more commonly prescribed drugs may not provide benefits that outweigh the risks of muscle aches and slowed thought processes.

Information on the number of prescriptions filled by Medicare in 2010 — by state, speciality and doctor — was released in May to the nonprofit investigative journalism organization ProPublica.

In addition to raising questions about the drugs being used, the data also provides a comprehensive look at the health problems that New Hampshire residents over 65 face. Six of the top 10 drugs treat high blood pressure, a condition that affects one in three Americans. It can be brought on by age, stress, weight gain or a diet that’s high in sodium. Two other drugs are used to treat high cholesterol, and one each hyperthyroidism and heartburn.

The heartburn drug raised concerns for multiple experts: omeprazole, the chemical name of the medicine Prilosec. According to ProPublica, in 2010 New Hampshire Medicare patients filled nearly 80,000 prescriptions for the drug, the fifth-highest number on the list. It’s commonly prescribed to patients during a hospital stay to prevent gastrointestinal bleeding from stress or as a result of other medications, but often ends up becoming a part of their daily routine. That’s risky, experts said.

Lori Connors, a pharmacist with Concord Regional Visiting Nurses Association, looks specifically for omeprazole when evaluating a client’s medication list — so she can advocate for discontinuing its use.

Other acid reflux and heartburn medications block only a specific type of stomach acid, while omeprazole shuts off the stomach’s acid pump mechanism entirely, she said. Hospitals give the drug to patients staying for almost any length of time, to prevent gastrointestinal problems from stress or other reasons, she said.

“But then they go home and nobody clarifies if you need to continue to take it,” she said.

“Typically, that kind of treatment should only run six weeks. I think the majority of the people on it don’t just fill their prescription once. It’s definitely overused,” and at more than $36 per prescription on average, is an unneeded expense for many patients, she said.

The effects of continued use of the medication aren’t yet known for sure, but are raising red flags, said Cheryl Durand, an assistant professor at the Massachusetts College of Pharmacy and Health Sciences’ Manchester campus and a pharmacist at Elliot Hospital.

The long-term effects are still being sorted out, but initial studies show a higher incidence of pneumonia, osteoporosis and bone fractures.

“I’m not saying it’s not safe, but initially we thought it was pretty benign and that the benefits outweighed the risks, so people just sort of stayed on it,” Durand said.

While some people do benefit from the relief from heartburn the medication provides, “we see a lot of people on it that may not need to be on it,” she said.

Doctors listed through ProPublica as frequently prescribing the medication didn’t return calls for comment.

Also on the List

Lisinopril, the second most commonly prescribed drug for New Hampshire Medicare patients, is part of the angiotensin converting enzyme (ACE) inhibitor class of drugs, used to treat high blood pressure.

Two other common drugs, metorprolol succinate and metoprolol tartrate, are also used to treat high blood pressure, but are part of the beta blocker class of drugs.

Beta blockers have “been around for years and years and are pretty darn effective,” said B.J. Entwisle, faculty geriatrician at the NH Dartmouth Family Medicine Residency at Concord Hospital. “They are also pretty safe, depending on the person,” though they can cause a slow heart rate, she said.

Amlodipine besylate, another blood pressure medication, is known to effectively treat the problem and is tolerated well by most patients, Entwisle said.

The drug most commonly prescribed to Medicare patients, in New Hampshire and nationally, is simvastatin, the generic form of the high cholesterol medication Zocor. In New Hampshire, another statin, Lipitor, also makes the top 10 list.

The use of both by patients over the age of 75 — part of Medicare’s core population — concerns Dennis McCullough, community geriatric consultant with the Dartmouth Centers for Health and Aging.

“More and more, so many people are taking statins, but for people who just have elevated cholesterol and not identified heart disease by age 75, there is not a clear benefit,” he said.

Age alone accounts for 75 percent of the 10-year risk of developing heart disease for 75-year-olds with high cholesterol, but only 12.5 percent of the risk for a group of 45-year-olds with the same cholesterol elevation, according to an article McCullough wrote recently for Generations, the journal of the American Society on Aging.

That means a statin that makes a lot of sense for a 45-year-old wouldn’t provide much benefit for a much older person, but would present the same risks, if not more, McCullough said.

Age isn’t the primary factor Entwisle would consider before prescribing a statin for a patient. A patient who has had a heart attack would benefit far more than a patient who only suffers from elevated cholesterol levels, she said.

“If you’ve had a heart attack, you should take it, there’s no question — it does help clean up the plaque-filled arteries and stop the ongoing damage to the heart,” she said.

“There is no guarantee that any pill can prevent a heart attack,” she said. “... For some doctors, though, they’ll say if Lipitor prevents one nonfatal heart attack in 300 people, they think that’s worth it for all the other 299 to be on it, too. I would say I don’t necessarily think it is.”

Side effects of statins include liver problems and muscle aches, and some studies show negative effects of cognition and memory as well.

Lipitor, in addition to being the 10th-most commonly prescribed drug, is also the most expensive drug on the top 10 list, though a generic was recently approved that is roughly $60 per month less expensive, according to Connors, the visiting nurse association’s pharmacist.

Lipitor and its generic are very effective cholesterol-lowering drugs, and can be given in higher doses than simvastatin, which has a higher incidence of side effects and interactions with other medications, she said.

For older adults taking statins, the risk of drug interactions is higher; most patients in long-term care facilities, for example, take between 10 and 15 prescription medications.

Older bodies also metabolize medications differently, so a dose that was effective for a 45-year-old may no longer be appropriate for the same person 30 years later, McCullough said.

“Patterns have emerged basically because there’s been a misrepresentation of what these drugs do and how they should be used,” he said. “Patients are paying the price and not always getting the benefit they think they are.”

McCullough recommends that patients bring a friend or family member to their primary care appointments to help them sort through information, and talk to their doctors about medication vacations, where they can stop taking prescriptions in a monitored way, to evaluate whether the benefits outweigh the side effects.

Again, New Hampshire physicians who were listed as frequent prescribers of statins didn’t return calls seeking comment, but the companies that manufacture the drugs said they are intended to be part of a health plan for patients at significantly increased risk for atherosclerotic vascular disease.

CORRECTION

This article has been amended to correct an earlier error. Lisinopril, the second most commonly prescribed drug for New Hampshire Medicare patients, is part of the angiotensin converting enzyme (ACE) inhibitor class of drugs, used to treat high blood pressure. Two other common drugs, metorprolol succinate and metoprolol tartrate, are also used to treat high blood pressure, but are part of the beta blocker class of drugs. The classes of drugs were incorrect in an earlier version of this article.