Sunday, June 22, 2008

The truth on the 8 drugs doctors wouldn't take

Shame on MSNBC for re-purposing this article originally found in Men's Health. This isn't even a survey of physician's experience with these supposedly dangerous drugs, and the expert most commonly quoted in the article is a pharmacist, not a physician. I recently mentioned the original article a week or so ago, when I posted about one of my asthmatic patients who was quite well controlled on Advair but wanted to stop the medication, because her husband had read the report. In hopes that other patients won't similarly be worried about these medications, I have listed the supposed dangers and the truth behind them below.

As a physician, these kind of reports really anger me. I am sure they sell magazines or newspaper, but cause needless worry for patients and potential harm. For example, for those patients taking Avandia, sales data indicate that though some patients switched to other agents when media reports surfaced about a potential harm, many patients simply stopped taking Avandia. In many cases, patients stopped the medication, without consulting with their physician. This would cause their sugars to go up, potentially causing many complications. I am really surprised that a legitimate news organization like NBC would post such a piece on its website.

Their claim: Advair "may contribute to as many as 5,000 asthma-related deaths in the United States each year."

The truth: This stat comes from the discussion section of a publication that did an analysis of studies (meta-analysis) containing salmeterol, a component of Advair. The truth is that study never answered the question of Advair safety. I outline all of the data in my recent post Good News for Asthma Patients, but the bottom line is that issue really only concerns salmeterol taken alone. When taken together with fluticasone (Advair is fluticasone +salmeterol) not only is it safe, but it is also one of the most effective medications for asthma. Since the introduction of medications like Advair the asthma death rate (4,000 is the correct number) has actually declined, not increased!

Their claim: For the diabetes drug Avandia (rosiglitazone) "people who took rosiglitazone for at least a year increased their risk of heart failure or a heart attack by 109 percent and 42 percent."

The truth: Avandia (and other TZD's like Actos) do in fact increase fluid retention that can lead to heart failure in those at risk. This is a well known and uncommon side effect that can be avoided if these medications are used appropriately. The heart attack risk, which comes from another meta-analysis (notice a trend here), that just simply isn't true. I discuss all the recent studies and analysis in my recent post Avandia Vindicated!

Their claim: People taking 200 mg of Celebrex twice a day more than doubled their risk of dying of cardiovascular disease

The truth: This is one of two drugs out of the eight that doctors might not actually take. The real heart attack risk was seen in Vioxx, which was why it was pulled from the market. The question of cardiac risk with Celebrex, being a similar drug, has been studied, and no conclusive risk can be found. However, more importantly, it doesn't seem to be any more effective than ibuprofen and naproxen, and it's benefit of not causing the stomach ulcers which can be caused by ibuprofen and naproxen is not as substantial as initially thought. Because of a possible risk of heart problems, and no clear benefit over generic drugs, most doctors probably wouldn't recommend Celebrex as a first line agent. That said, certain patients who do well on it shouldn't all of a sudden stop this medication, because their is no clear heart risk.

Their claim: "This antibiotic, which has traditionally been prescribed for respiratory-tract infections, carries a higher risk of severe liver side effects than similar antibiotics do."

The truth: This is the other drug that doctors probably wouldn't recommend. The reality is that ALL antibiotics are over-prescribed, and there are now very resistant bugs in the community that were once limited to the hospital. The good news is that azithromycin, amoxicillin, ciprofloxin, and others are all generic, work well, and are pretty safe. However, they should used sparingly. Ketek, if ever used, should reserved for only rare infections where any of the other older, generic antibiotics wouldn't be used.

Prilosec and Nexium
Their claim: " The FDA has investigated a suspected link between cardiac trouble and the acid-reflux remedies."

The truth: What????? Even they say the FDA found no evidence of a link. Sometimes heart burn symptoms can really be a heart attack, and taking these medications might delay the diagnosis of someone with an actual heart problem. However, this doesn't mean the medications aren't safe. Prilosec is even over the counter. Both are extremely effective in suppressing acid and making miserable patients happy. The link between acid suppression and pneumonia is unclear, and this is really only for people who are hospitalized or otherwise at risk, such as nursing home patients. They have been shown to be substantially better than H2 blockers such as Zantac. I don't think I know a physician that WOULDN'T recommend Prilosec or Nexxium to a patient with acid reflux.

Their claim: "Overuse of the active ingredient tetrahydrozoline can perpetuate the vessel dilating-and-constricting cycle and may cause even more redness."

The truth: OK, but so what. Almost every over the counter medication states how much and how often you should use a medication. There are many medications that if overused, or not used correctly, can cause problems. This doesn't mean that physicians wouldn't recommend Visine or similar OTC eye drops.

Their claim: "pseudoephedrine doesn't just constrict the blood vessels in your nose and sinuses; it can also raise blood pressure and heart rate, setting the stage for vascular catastrophe."

The truth: Pseudoephedrine was one of the most common medicines used in cold medications until some kids started making crystal meth with it. You can still get this, but it is placed behind the counter. Most cold medicine makers replaced Pseudoephedrine with phenylephrine, another decongestant, which doesn't work quite as well. Even Sudafed doesn't have pseudoephedrine in it anymore! These medications have been taken by millions of people for many years, and there have been no reported dangers. They can raise your blood pressure, which could be a concern if you already have high blood pressure. However, for most people they are quite safe and shouldn't be listed as a "dangerous" medication.


Liana said...

Yes! I saw this article a few weeks ago and wrote a post about it on my blog as well (

As I wrote in my post, what bothered me the most about the article was the implication that doctors are maliciously and knowingly exposing their patients to drugs that are harmful even though there are better options out there.

Good post. I like how you addressed each of the drugs specifically.

Anonymous said...

I agree with liana, it's excellent the way you addressed each drug individually. I could not have said it better myself. Shame on MSNBC.

Anonymous said...

Finally! Just pay attention to your friends and family members who insist on taking these drugs. I find that they end up with more problems than they began! Why aren't doctors using diet, and lifestyle choices to guide their patients to better health?

Dr. Matthew Mintz said...

I will try and post soon on a follow up to this. Bottom line is that when polling over 100 physicians, virtually none agreed that these drugs were dangerous, with the exception of Ketek.
Doctors do focus on diet and exercise. For the drugs listed, the only 3 (avandia, celebrex, and Nexxium/Prilosec) can be managed by diet and exercise. In regards to diabetes, diet and exercise is essential, but alone may not be enough. Patients generally require multiple medications, so use of medicines like Avandia are often necessary. Exercise and weight loss is helpful for osteoarthritis, especially weight loss for weight bearing joints like the back and knees. However, once a patient has pain, damage has already been done, so again, medication is often necessary to relieve the pain (in this case taking OTC meds like naproxen is probably a better idea then Celebrex). GERD is multi-factorial, and obesity is only one factor. Certain foods (high acidity foods like tomatos and spicy foods) can certainly trigger this. Again, diet and exercise is important, but in many cases is not enough.

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Anonymous said...

I wonder if they'd take Levaquin or Avelox??

Or how many took Vioxx??

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