Multiple Medications Needed

'Polypharmacy' is medicalese for the circumstance where someone is taking multiple medications, and it has an increasingly bad name.  That's largely because polypharmacy is most frequently seen in elderly people, who may experience a host of deleterious side effects of medications that often last longer in them than in younger people, and may also have trouble remembering the proper regimen for each drug so may not be taking it as prescribed.  But a study in this week's New England Journal of Medicine demonstrates one condition where polypharmacy appears to be  a good thing: congestive heart failure.

Congestive heart failure or CHF, I observe in this week's podcast, may be viewed as a success story in medicine.  That's because most people have to live long enough to develop it.  The bad news about CHF is more and more people are developing it, and it's a major cause of death. In fact, after the age of 65 we are more likely to be hospitalized for CHF than for any other medical condition.  It's expensive, too.  Trying to deal with the consequences of CHF costs the healthcare system millions each year, and accounts for some very high ticket items like left ventricular assist devices and other bits of technology.

So what do we learn in this study, one that Rick calls practice changing?  Almost 3000 people with mild symptoms of heart failure and who were already taking two standard issue medications for the condition, an ACE inhibitor and a beta blocker, were randomized to receive a third drug that inhibits a hormone called aldosterone, or not.  Those who received the aldosterone inhibitor experienced a much reduced risk of either hospitalization for heart failure or death due to cardiovascular causes than those who did not, so much so that the trial was stopped early so that the results could be published and more people might potentially benefit from this treatment.

Hrumph.  Now here comes a condition where more is better when it comes to medications?  Heresy!  Rick points out in the podcast that it sure seems like people with early CHF should be taking all three drugs, but that's likely to be a tough sell when they're just experienced mild symptoms.  It's a lot like the problems seen with management of high blood pressure, where people feel just fine, thank you, when their blood pressure is high, and often much more sluggish when it's brought under control, so they stop taking their medication.  Yet the data is compelling for use of all three agents early in the course of the condition.

What about cost?  Rick agrees with the editorialists in the same issue of NEJM that instead of eplerenone, which is quite expensive, spironolactone, another aldosterone inhibitor, may be tried first.  It's considerably less expensive.  It's also worth remembering that good medical management of CHF is likely to be less expensive over the long term than hospitalizations and devices needed due to worsening of the condition.

Other topics in this week's podcast include potential inappropriate placement of internal defibrillators in JAMA, a low tech assessment of walking speed as a predictor of survival in the elderly in the same journal, and back to NEJM for an antibiotic potentially useful in irritable bowel syndrome.  Until next week, y'all live well.

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Brysen September 3, 2011 at 8:08 pm

Good point. I hadn't toghuht about it quite that way. :)

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