I devote some time each day to keeping up with the latest on conventional diagnostic and treatment methods, along with the most recent research on botanicals, supplements, and other natural approaches to healing. It's what I do to be the best integrative physician I can be. This is no small feat, because as an MD trained in internal and family medicine, pretty much everything is in my wheelhouse to treat. So one of the ways I try to stay on top of the latest is through medical news feeds, Medscape being my personal choice. The title of this article is inspired by the title of a recent Medscape piece: 11 Drugs You Should Seriously Consider Deprescribing. It’s one of several articles of the sort over the past year, encouraging doctors to actually learn the evidence for many of the most commonly prescribed pharmaceuticals, to stop prescribing blindly, and overall to prescribe less.
Amongst the pharmaceuticals recommended to deprescribe are:
- Stool softeners (i.e., Colace): They are routinely recommended for most hospital patients, and prescriptions are typically given on hospital discharge, yet there is no evidence of efficacy.
- Proton pump inhibitors (PPIs): PPIs not only contribute to Small Intestinal Bacterial Overgrowth by reducing the protective stomach acid we need to keep upper gut bacteria in check, but are also associated with reduced calcium and B12 absorption, potentially increasing risks of fracture and neuropathy. They also interfere with thyroid hormone absorption, so if you’re taking a thyroid medication, you may not be absorbing your full dose. While some individuals may need a PPI for a short time, they are associated with rebound acid reflux making them difficult to come off of (I take patients off of these all the time), and too often they are prescribed unnecessarily.
- Statins for primary heart disease prevention: Statin use has gone up substantially since 2013 when the AHA recommended them for primary prevention of a heart attack; however, the evidence for their use for this purpose is scant, and actually completely lacking for individuals over age 75. Studies have found that putting a woman on a statin for primary prevention increases her risk of developing diabetes, even in women who were previously low risk for diabetes.
- Z drugs – or the benzodiazepenes like zolpidem, zaleplon, and eszopicline for sleep: The use of these medicaitons is an all too common and very dangerous practice. Benzos have not only been linked to Alzheimer’s, but studies show that sleep medications in general, across the board, seriously increase a woman’s likelihood of being in a car accident due to impaired reflexes and cognitive function from the medication.
- Beta-blockers: New studies show that they are not only ineffective for long-term therapy (> 3 years) after a heart attack, but that they might not be that effective for immediate post-MI therapy, or even for blood pressure reduction. Yet they have been the mainstay of treatment since 2011.
- And the list goes on.
Special Risks to Women
Most medications have never been tested in women while 70% of all pharmaceuticals are prescribed to us. According to one survey, 50% of female Medicare recipients were on at least 5 medications per day, with 12% on 10 or more. Yes, please, take that number in. Differences in how women metabolize medications put us at greater risk for adverse events compared to men. Even medications we’ve relied on for common symptoms, ibuprofen for menstrual cramps and migraines, for example, have been associated with adverse effects – in the case of ibuprofen, there’s an increased risk of heart attack in women even with infrequent use, and just 10 days of use has been found to reduce fertility temporarily. Yet pharmaceutical advertising strategically downplays the risks to both practitioners and the general public, while exaggerating the benefits to both of us through direct-to-consumer advertising and professional journals. Women’s bodies are big business for a number of extremely profitable industries. Too often, the recommendation to prescribe less and more discriminately is falling on deaf ears.
Overprescribing of pharmaceuticals has implications not only for the women taking the medications, but also the health of our planet. A 2016 study of fish in Puget Sound found they were contaminated with a veritable pharmacy of medications from Prozac to caffeine to cholesterol medicine, from ibuprofen to bug spray, to personal-care products. What we take, we excrete, and we are contaminating our planet with pharmaceutical waste. Even when it comes to supplements, most are not plant-based or organic; instead they involve the use of complex solvents and other processing materials, and their packaging accounts for a substantial amount of waste.
Fortunately, I spent over 25 years as an herbalist and midwife before venturing into the world of medical practice, allowing me to avoid the pitfalls of overprescribing, and prescribing in the absence of evidence. I got my medical degree so that I could have more of a voice in helping women make healthier, safer choices, and so I could reinvent how women experience health and health care. Having spent decades watching trends in conventional medicine, I spend more time getting women off of unnecessary medications, than prescribing them. Nowadays, ditto that with supplements.
It’s not just Big Pharma that’s seeking to profit off of misinformation and sales. The supplement and functional medicine worlds are quickly becoming a new Wellness Industrial Complex. The supplement industry in the US alone is now a $12 billion a year industry; added to that are billions in testing options that aren’t always highly validated or accurate. There is tremendous incentive in creating diagnoses, selling sickness and selling supplements. Even botanical medicine has gotten swept up in the “frenzy” – ashwagandha products alone now generate about a $200 million a year in sales. Yet there is often a complete paucity of data behind many – if not most – of the claims made for supplement efficacy, creating a caveat emptor situation in a growing wild west both for practitioners and consumers/patients.
So what can you do as a practitioner? Learn how to practice conservative prescribing. This means making the commitment to thinking first, and prescribing less, only when necessary, and the least number of products, whether medications or natural alternatives. If you're not a prescribing practitioner, it’s still important to be able to educate your clients regarding the safety of what they are putting into the same body you’re trying to help them heal. Providing information they can bring back to their prescribing provider so they can get de-prescribed medications (or supplements) that are just not benefitting is an important part of their health. And if you are recommending supplements, this all applies directly to your practice.
To practice conservative prescribing ask yourself the following 8 Prescribing Guidelines before making any recommendations:
- If considering a medication, are there lifestyle or nutritional, supplement, or botanical alternatives to this medication that have comparable or greater efficacy and safety?
- If considering a supplement or botanical, are there lifestyle or dietary alternatives that have comparable or greater efficacy and safety?
- Is this medication or supplement really necessary for this woman?
- Is there evidence to support efficacy?
- Is it reasonably safe and do the benefits for this woman adequately outweigh the risks?
- What are the woman’s personal preferences and how can those be honored as well?
- What are the cost considerations of the various treatment options to the woman?
- Is there a choice that is ecologically preferable?
And also, learn which alternatives really work. Here are some examples of nutritional and supplement alternatives for the medications I mentioned earlier, that are also ecologically sound and affordable, and are evidence based:
- Instead of stool softeners: First, can a dietary change, for example, increasing fiber with more vegetables and fruits, make the difference. Alternatives? Psyllium, which is safe and at a dose or 5 grams per day, does work according to a randomized controlled trial (RCT) comparing the two. Or try senna, which in another clinical trial, also surpassed the efficacy of the conventional option.
- Instead of a PPI, try dietary and lifestyle strategies, or consider a supplement alternative, for example melatonin, which, in one small study, was associated with a notable decrease in heartburn symptoms at a dose of 3 mg in the evening, is thought to be strengthening of the lower esophageal sphincter, and is safe.
- For sleep help, start with sleep hygiene and a circadian rhythm reset. Numerous herbs and botanicals can improve sleep quantity and quality with easily comparable efficacy to most sleep medications which increase sleep by up to at most usually, 30 minutes per night, without the risk. Examples include valerian, hops, passionflower, vitamin B12, melatonin, and magnesium.
- And when it comes to heart health, the Mediterranean diet is a profoundly effective method for reducing cardiovascular risk, both by preventing but also reversing disease – improving both cholesterol and blood pressure. Garlic has been shown in major meta-analyses to improve cholesterol, and 2 TBS olive oil per day, eaten in food, has been proven effective for primary prevention of a heart attack.
So let me ask you: psyllium or a stool softener? Statins or olive oil for primary heart disease prevention? Let’s ponder that, but not for too long, because patients can’t wait for safer alternatives. Their lives are on the line.
How to Learn What Really Works – and Doesn’t
Knowing what really works, versus what dozens of online faux experts echo each other about, regardless of their knowledge, training, experience, or having read the research – is really hard and takes a commitment to understanding the research. I don't want to recommend products to my patients just because an online wellness celebrity or author said that it works. I want to give my patients options that really work, are safe, don’t break their bank account, and don’t have them popping 20 or 50 pills a day!
I want to help my patients truly transform their lives and their health. My guess is you do to! That’s exactly what you’ll learn by staying tuned to this new casual but hard hitting clinical pearls feature I’ll be bringing to you – in the form of both mini-newsletters, Facebook and Instagram live practitioner events, and video updates. All you have to do is check your inbox now and then for health professional updates from me. Not too many to clutter your inbox, just enough to keep you looking forward to the next. All free.
Let’s reinvent woman’s health together.
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