Medications That Put Our Seniors in the Hospital

Summer Flowers (Dr. Noorali Bharwani)
Summer Flowers (Dr. Noorali Bharwani)

I covered this topic about three years ago. It is never too early or too late to review the subject again.

A study published in the New England Journal of Medicine says 40 percent of people over 65 take five to nine medications every day. What this means is that hospitalizations for accidental overdoses and adverse side effects are likely to increase among this group.

The study found that every year, about 100,000 people in the United States over age 65 are taken to hospitals for adverse reactions to medications. Most of the patients are there because of accidental overdoses. Sometimes the amount of medication prescribed for them had a more powerful effect than intended.

The four most common groups of medications putting seniors in hospitals are: warfarin (a blood thinner), insulin injections for diabetes, antiplatelet drugs to thin the blood and oral diabetes drugs.

Warfarin accounts for the most visits due to adverse drug reaction. It accounted for 33 percent of emergency hospital visits. Warfarin (Coumadin) is an anticoagulant – popularly referred to as a “blood thinner.” In reality, it does not make the viscosity of the blood thin. What it does is that it acts on the liver to decrease the quantity of a few key proteins in blood that allow blood to clot.

It was initially marketed as a pesticide against rats and mice. Later it was found to be effective and relatively safe for preventing blood clots in humans. It was approved for use as a medication in the early 1950s and now it is the most widely prescribed oral “blood thinner” drug in North America.

Insulin injections were next on the list, accounting for 14 percent of emergency visits. Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body.

Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle. When control of insulin levels fails, diabetes mellitus will result. Patients with type 1 diabetes depend on insulin injections.

Antiplatelet drugs like aspirin, clopidogrel (Plavix) and others that help prevent blood clotting were involved in 13 percent of emergency visits. An antiplatelet drug is a member of a class of pharmaceuticals that decrease platelet aggregations and inhibit clot formation. They are effective in the arterial circulation, where “blood thinners” have little effect.

Lastly, diabetes drugs taken by mouth, called oral hypoglycemic agents, which were implicated in 11 percent of hospitalizations. Anti-diabetic medications treat diabetes mellitus by lowering glucose levels in the blood. There are different classes of anti-diabetic drugs, and their selection depends on the nature of the diabetes, age and situation of the person, as well as other factors.

The authors of the article say that in order to reduce the number of emergency hospitalizations in older adults we should focus on improving the safety of this small group of blood thinners and diabetes medications, rather than by trying to stop the use of drugs typically thought of as risky for this group. And patients should work with their physicians and pharmacies to make sure they get appropriate testing and are taking the appropriate doses.

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Leg Ulcers can be Prevented After Deep Vein Thrombosis and Post-Thrombotic Syndrome

Kin Coulee Park in Medicine Hat has more than one thing to offer. (Dr. Noorali Bharwani)
Kin Coulee Park in Medicine Hat has more than one thing to offer. (Dr. Noorali Bharwani)

The title of this column suggests three interrelated health issues – deep vein thrombosis, which may lead to post-thrombotic syndrome, and in some cases the individual may end up with chronic leg ulcers.

Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein, usually in the legs. Post-thrombotic syndrome is a complication of DVT and can affect 23 to 60 per cent of patients in the two years following DVT of the leg. Of those, 10 per cent may go on to develop venous ulcers.

The presentation of DVT and post-thrombotic syndrome may be quite similar. Seventy to 90 per cent of chronic leg ulcers are due to improper functioning of venous valves of the legs. It is important to remember post-thrombotic syndrome is a chronic but preventable condition. Otherwise it leads to limb pain, swelling, skin discolouration, ulceration, and rash after DVT.

An article in the Canadian Medical Association Journal (CMAJ January 7, 2014) describes the risk factors for the post-thrombotic syndrome, which include older age, obesity, male sex, iliofemoral (proximal) DVT, recurrent same side DVT, previous or primary venous insufficiency, and elevated D-dimer levels after withdrawal of anticoagulant agents.

Any individual who has had DVT should be advised regarding the long-term consequences of damaged valves in the deep veins and preventive measures. These include using compression stockings and taking low-molecular-weight heparin for at least three months after DVT is diagnosed.

Compression stockings and exercise therapy are first-line treatments for the symptoms of post-thrombotic syndrome.

A Cochrane review reported that compression stockings (30 to 40 mm Hg) used early after the diagnosis of DVT were associated with a 69 per cent reduction in the odds of post-thrombotic syndrome developing.

A systematic review also showed that long-term treatment with low-molecular weight heparin after DVT resulted in a lower incidence of post-thrombotic syndrome than treatment with anticoagulants administered orally.

The aim of management is to prevent further incidence of DVT and prevent long-term consequence in the form of chronic leg ulcers, which are not easy to treat.

An article in the American School of Laughter Yoga website titled, “Laughter helps leg ulcers heal.” quotes Dr. Andrea Nelson, University of Leeds School of Healthcare saying, “Believe it or not, having a really hearty chuckle can help too (with leg ulcers). This is because laughing gets the diaphragm moving and this plays a vital part in moving blood around the body.”

Once again, remember, more you laugh the better you get and better you feel.

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Preventing Stroke Important for Independent Lifestyle

Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)
Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)

“There are many ways of breaking a heart. Stories were full of hearts broken by love, but what really broke a heart was taking away its dream – whatever that dream might be,” said Pearl S. Buck (1892–1973), a bestselling and Nobel Prize–winning author.

What stroke does to a person is to take away a dream. But where there is a will there is a way. Two basic things required for any kind of success are: patience and perseverance. With appropriate help from family, friends and caregivers much can be achieved, although it may take time.

What is more important is to prevent stroke in the general population and especially people who are at a high risk.

A commentary in the Canadian Medical Association Journal (CMAJ November 19, 2013) titled, “Stroke prevention in older adults with atrial fibrillation,” by Michiel Coppens, MD and colleagues, discuss the use of new oral blood thinners that reduced the risk of bleeding in the brain by 30 to 70 per cent compared with warfarin. The new medications were at least as effective as warfarin in preventing stroke due to reduced blood supply to the brain.

People with atrial fibrillation have irregular heartbeats, which make them prone to forming blood clots. Warfarin is the most commonly used drug (also used as rat poison) as a blood thinner in humans to prevent blood clots. The main drawback is that the patient has to have regular blood tests to make sure the blood is not too thin. It may cause internal or external bleeding.

The new oral blood thinners (dabigatran, rivaroxaban and apixaban) are approved in more than 80 countries for stroke prevention in patients with atrial fibrillation. Patients do not require blood tests to check if the blood is dangerously too thin.

According to the CMAJ article, the key points to remember are that many patients do not receive recommended blood thinner treatment. The new oral blood thinners offer consistent benefits over warfarin in older (age 75 years or older) patients with atrial fibrillation.

The article says the rate of internal brain bleeding, the most feared complication of blood thinners, is related to age and is sharply reduced by the new blood thinners relative to warfarin, making these agents particularly attractive for older patients.

Like any new medication, only time will tell whether the drugs are safe and superior to currently used warfarin or should I say rat poison? Talk to you again soon. Take care and don’t forget to listen to music, dance and laugh.

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A New Blood Thinner to Prevent Stroke

A doctor reviewing MRI films. (iStockphoto)
A doctor reviewing MRI films. (iStockphoto)

It was only a year ago, I wrote about a new blood thinner (dabigatran) to prevent stroke in patients with irregular heart rhythm. Now we have a second drug (rivaroxaban) for the same indication. This is good news for patients who are on blood thinners like warfarin – a rat poison.

About 350,000 Canadians suffer from irregular heart rhythm called atrial fibrillation (AF). In the U.S. there are approximately 2.3 million adults with AF. The commonest cause of AF is getting old. The lifetime risk of getting AF is one in four after the age of 45. Before that it is not that common. Occasionally, you do see patients in their 20s and 30s.

Most common causes of AF are: hypertension, valvular heart disease, alcohol excess, thyroid disease, obesity, sleep apnea, genetic predisposition and it can be idiopathic (cause unknown). What I call GOK – God only knows!

The most dangerous complication of AF is stroke. It accounts for up to 36 percent of all strokes in elderly people. The cost of looking after patients with stroke runs into millions of dollars.

In order to prevent stroke, patients with AF are converted to regular (sinus) rhythm by applying direct-current electrical shock (cardioversion), by medications or by ablation therapy. If it is difficult to sustain regular rhythm, then the patients receive blood thinners (like warfarin) on a regular basis to reduce the risk of stroke by 70 percent.

The main advantages of warfarin are that it is cheap and is covered by provincial drug plan. Major disadvantages are that you need frequent blood tests to make sure that the blood concentration of the drug is at a safe level to keep the blood thin. But not dangerous enough to make you bleed in the brain or some other place. It is quite difficult to achieve the safe level and maintain it.

Over the years, there has been great amount of research to find a drug to replace warfarin. Last year, dabigatran (Pradax) was introduced. This year we have rivaroxaban (Xarelto) in the market. These new blood thinners do not require regular blood tests.

Rivaroxaban is an oral blood thinner invented and manufactured by Bayer as Xarelto. Rivaroxaban is well absorbed from the gut and maximum inhibition of factor Xa occurs four hours after a dose. The effects last eight to 12 hours, but factor Xa activity does not return to normal within 24 hours so once-daily dosing is possible. Compared to dabigatran which is to be taken twice a day. The daily dose for rivaroxaban is usually 20 mg once a day.

The newer oral blood thinners have been found to be better in preventing stroke than warfarin and the risk of side-effects like bleeding is less than warfarin. And remember – no blood tests.

There are two significant disadvantages to taking the newer drugs. One, there is no antidote to convert your blood to normal if you have a significant bleed after trauma or bleeding due to another cause. The mortality rate can be high. Second, the pills are expensive. So, you have to check with your insurance company if the cost of the pills will be covered. Xarelto is slightly cheaper than Dabigatran because of once a day dosage.

Now, only if we can permanently prevent atrial fibrillation, warts, common cold and hemorrhoids (just to mention a few) then life will be good. You won’t have to choose between the devil and the deep sea. But some of us will be out of business.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!