When your doctor prescribes a drug it means you really need it, right? Wrong! In fact, every year, millions are given medicine that’s completely unnecessary or inappropriate.
Quite apart from the huge waste this represents for health care systems, these drugs can have harmful, even fatal side-effects — something the family of Mary McIlgorm, an 83-year-old from Barrow-in-Furness, in Cumbria, learned too late.
Mary had suffered with mild indigestion for years, recalls her daughter Christine, 54, a Post Office clerk. ‘But Mum had always got by with over-the-counter remedies and it really didn’t bother her too much,’ she says. ‘Then one day her GP prescribed a drug called lansoprazole.’
This is one of the proton pump inhibitor (PPI) drugs, which work by cutting the amount of stomach acid you produce.
PPIs are used for treating stomach ulcers and heartburn and have rapidly become one of the most frequently prescribed groups of drugs. However, studies have shown that up to 70 per cent of prescriptions for them may be unnecessary. Mary knew none of this.
‘Mum was instructed to take a pill every day, but she told me they didn’t seem to be very effective and she still suffered from indigestion,’ says Christine.
Later that year, when Mary suffered a fall and broke her arm, she was admitted to hospital. There she caught Clostridium difficile, a superbug that causes severe diarrhoea and is potentially fatal. Three weeks later Mary died.
Christine later learned that PPIs are known to dramatically raise the risk of contracting
C.difficile — some experts believe they are linked to hundreds of deaths in the UK every year.
‘I was so angry when I found out about this, especially when Mum probably didn’t need the drug in the first place,’ says Christine. ‘Her death was completely avoidable.’
Mary’s experience is far from an isolated case. There are as many as 15 groups of drugs which are overprescribed, according to guidelines just issued by the NHS National Prescribing Centre. These include some of the most commonly used medicines for arthritis, insomnia and asthma.
There’s no denying that these drugs, when correctly prescribed, can transform patients’ lives for the better. The worry is when they are doled out unthinkingly, says Dr Martin Johnson, a former GP and trustee of the Patients’ Association.
‘Unfortunately, patients can sometimes end up on drugs they don’t need and these can have side-effects which impact on quality of life and make them feel unwell.
‘They can also cause long-term side-effects such as kidney disease or increased stroke risk. The elderly suffer more because they are more likely to be on multiple prescription drugs and be more susceptible to side-effects.’
Indeed, between 16 and 30 per cent of all hospital admissions in the elderly are caused by inappropriate prescribing, says Dr Mehool Patel, of University Hospital, Lewisham, who is the deputy chairman of the British Geriatric Society’s Council.
‘Increasingly, geriatricians are seeing elderly patients on lots of different types of drugs they don’t need.
‘Coping with drug side-effects is a big issue for the elderly. For instance, many elderly patients are prescribed a drug called prochlorperazine for dizziness. It’s meant to be a short-term treatment, but if patients are left on it long term they develop Parkinsonism — that’s Parkinson’s disease symptoms caused by drugs.’
Overall GPs in this country are some of the ‘best prescribers’ in the world, says Peter Rowe, who runs the Department of Health’s team for assessing medicine use and procurement. ‘But we can always do better.’
Part of the problem is patients are often given repeat prescriptions and no one reviews their medication.
For instance, patients with long‑term heartburn symptoms are meant to have an annual review of their treatment and helped to reduce or stop it. In fact, many are not reviewed but left on long-term, high doses of PPIs.
There needs to be ‘much more accountability for prescribing’, says Dr Johnson.
‘When I was a GP, I would never have put anyone on a repeat prescription unless I’d reviewed them to see how they were getting on and whether the drug was still necessary. That’s just one simple step to avoid unnecessary prescribing.
‘I think another is for patients to actually ask their doctors whether they really need a prescription.’
So are your prescription drugs unnecessary and even harmful? Here, with the help of experts, we identify the main drugs causing concern.
The most commonly prescribed drugs for heartburn are PPIs. They are also used to treat stomach ulcers and to counter the gastric side-effects of painkilling drugs used to treat arthritis, such as diclofenac.
Last year alone there were 36mmillion prescriptions written for PPIs, a three-fold increase since 2000.
Not only are these prescriptions often unnecessary, the drugs dramatically increase the risk of catching potentially fatal C.difficile, raising your chances by as much as 80 per cent, according to a review of studies involving 133,000 patients.
It seems PPIs destroy the stomach acid barrier which protects ‘friendly’ gut flora; this allows harmful bacteria to flourish.
The drugs increase the risk of osteoporosis and fractures, possibly by preventing calcium absorption.
PPIs have also been associated with a 30 per cent increased chance of developing pneumonia in intensive care.
PPIs may be responsible for hundreds of extra deaths annually, says Dr Richard Cunningham, consultant microbiologist at Derriford Hospital.
‘The risk of patients developing C.difficile is now well-established, but it seems to be taking a long time for that information to be reflected in prescribing practice,’ he says.
‘A high proportion of patients admitted to A&E and acute medical units are on PPIs — up to 40 per cent in some areas — and the worrying thing is that when many of these patients are interviewed, most don’t even know when or why they were prescribed them.’
In fact, research shows only around a third of patients actually have serious conditions such as peptic and duodenal ulcers that require this powerful treatment.
‘Doctors are prescribing an unnecessarily potent drug for mild indigestion when lifestyle advice or a much simpler drug would be much safer,’ adds Dr Cunningham.
‘In the past, patients would have been advised to lose weight, prop up the head of their bed higher (to lessen the chances of acid coming back up from the stomach) and avoid spicy food, or at the very most take an over-the-counter antacid treatment.’
Professor Roger Jones, author of a King’s Fund report, Managing Acute Illness, adds that handing out reassuring advice on prevention rather than pills can be far more useful.
‘In some cases prescribing PPIs became almost a knee-jerk reaction for any patients with indigestion,’ he says. ‘Doctors often defend their prescribing by arguing they come under pressure from patients to give them a prescription, but there’s good research to suggest doctors tend to overestimate this.
‘Many patients may feel better with a good deal of reassurance and advice on preventing their problem reoccurring.’
Another group of drugs doled out too readily are those for arthritis.
The non-steroidal anti inflammatory drugs (NSAIDs) are some of the most commonly prescribed painkillers in general practice. However, recent studies have linked them to a higher risk of ulcers; the drugs stop the body producing chemicals called prostaglandins, which it needs to protect the stomach lining.
Meanwhile, diclofenac — the most popular NSAID — may also raise the risk of stroke. Some experts say the drug is linked to up to 2,000 extra or premature heart attacks and strokes a year.
‘It is also very important to consider non-drug treatments. For example, in patients with osteoarthritis of the knee there are so many things that can help, including thigh muscle-strengthening exercises, weight reduction and use of shock-absorbing shoes or insoles.
The worry with the overprescription of insomnia drugs is that users can quickly become addicted, which is why doctors are told to prescribe them for just a few weeks at a time.
There are two groups of insomnia drugs: the benzodiazepines, which include diazepam (previously known as Valium) and alprazolam (brand name Xanax); and the newer, so-called ‘Z’ drugs — Zolpidem, Zaleplon and Zopiclone. These are all used to treat severe insomnia and severe anxiety.
The risk of addiction from benzodiazepines has been recognised for years, and under official guidelines they’re meant to be used only if insomnia is severe, disabling or causing the patient distress.
Last month, the Earl of Sandwich spoke in the House of Lords to highlight the dangers of benzodiazepine over-prescription, revealing a member of his family has been suffering from withdrawal symptoms for the past 18 months.
He said: ‘These drugs are dangerous. Why do doctors prescribe them so freely if they provide temporary relief for so little time and never cure the problem?’
Other potential side-effects of benzodiazepines include dizziness, memory problems, day time sleepiness and, in some cases, an increase in anxiety levels. Withdrawal symptoms can be severe and disabling.
Antibiotics are still widely being used to treat viral infections —– despite the fact that the drugs have no effect on them at all. They are prescribed for 81 per cent of otitis media (ear infections), 91 per cent of acute sinusitis, 60 per cent of sore throats, 47 per cent of laryngitis and even 26 per cent of influenza cases — even though a high proportion of these illnesses and all cases of flu are caused by viruses.
The concern is largely that the overuse of antibiotics will lead to more superbugs, resistant to treatment.
But patients have a more immediate reason to want to avoid having antibiotics, as Professor Avery explains: ‘There’s evidence that they can increase the patient’s risk of developing resistance to the use of similar antibiotics in the future, when they may need treatment for a more serious infection.
‘There is also a major concern — particularly in older people — that frequent use of broad spectrum antibiotics (which work against a wide number of bacteria) increases the risks of C.difficile, which can be fatal.’
Other side-effects from taking antibiotics include diarrhoea, nausea and vomiting.
If you’re treated with broad spectrum antibiotics there is a risk of developing a fungal infection afterwards, such as thrush.
High-dose inhaled corticosteroids are often used for asthma, but if taken at high dosage for long periods they can potentially cause glaucoma and cataracts, slow growth in children and adolescents and suppress the adrenal gland (which produces important hormones such as cortisol).
The British Thoracic Society recommends the dose is reviewed every three months, reducing it by 25 to 50 per cent each time.
However, this is not routinely implemented, leaving some patients overtreated, a report found.
The drug ezetimibe works by inhibiting absorption of cholesterol.
Despite the huge increase in prescriptions, the National Prescribing Centre says there’s no good evidence the drug reduces the risk of heart attack or stroke compared to a statin alone.
Potential side-effects include dizziness, headache, muscle pain and disorders, constipation and diarrhoea.