Deprescribing as Treatment
By Dr. Richard Amerling, MD
Chief Academic Officer of The Wellness Company
The shift away from natural remedies and healthy diets to prevent and treat illness began in earnest with the Flexner Report, commissioned by John D. Rockefeller and Andrew Carnegie, around the turn of the 20th century.
While obvious benefits followed the emphasis on scientific research, the caring, clinical aspects of the profession suffered. Over time, the focus shifted towards pharmaceutical treatments of disease, treatment of symptoms rather than causes, and finally treatment of “risk factors,” that is, numbers rather than patients.
This pretty much sums up the curriculum of most, if not all, medical schools today.
This movement accelerated with the pharmaceutical industry’s hijacking of evidence-based medicine (EBM) to produce practice guidelines, written by so-called experts with industry-related financial conflicts of interest that inevitably push more and more prescribing.
The majority of practicing physicians abandoned their fiduciary responsibility to their patients and turned to these practice guidelines rather than applying critical thinking and clinical reasoning.
The unhappy result has been massive overprescribing and iatrogenic disease.
It is widely accepted that medication errors are a leading cause of morbidity and mortality in the US. The statistics grossly underestimate the extent of this already huge problem because the majority of guideline-promoted prescriptions are, in our view, medication errors!
I’m not discussing short courses of drugs for acute conditions such as infections, traumatic pain, and asthma. Medications certainly play a useful role in many situations. Neither am I concerned with chronic replacement of deficient hormones, such as thyroid or sex hormones. I’m exclusively focused here on long-term (i.e. lifetime) prescriptions of medications for chronic diseases.
The Aha! Moment
In my younger days, I was an enthusiastic prescriber of drugs I now know to be unhelpful and/or harmful. While tending towards a more conservative approach, a major 'Aha!' moment came in 2010 when a friend asked me to help her 90-year-old mother who had recently been sent home after a hip fracture, and who had sutures embedded in the subcutaneous tissue of her arm that needed to be removed.
Rather than send her to the ER, I made a house call and took care of it. I was struck by the observation that this previously vital and fully functional senior, who had been successfully living alone, was completely bedridden and very lethargic.
I asked my friend what medications her mom was taking and she produced a bag with over 10 bottles of pills. There were a couple of antihypertensives, a statin, one or two diabetes pills, an antipsychotic, aspirin and a few more. None were indicated, especially considering her advanced age. I told her to stop them all, with the exception of a low dose of a beta-blocker. Within a few days, she was out of bed and basically back to her old self.
I wondered how many others were in a similar situation. Probably many millions.
Overprescribing is particularly egregious in the elderly, who often have reduced liver and/or kidney function so are vulnerable to drug accumulation. And where’s the benefit?
Most medications are tested in young, healthy populations, and reported benefits are usually small and develop over many years. If the time horizon is limited, there’s less chance any benefit will be realized. Toxicity, however, will still be a problem. All medications have toxic side effects, and drug interactions are a whole other can of worms.
These are questions you should ask your current primary care provider about your prescriptions:
- What disease is this drug treating?
- What is my risk of hospitalization, other serious event, or death from this disease?
- To what extent does taking this drug reduce my risk, in absolute (not relative) terms? For example, a reduction in risk of a heart attack from 3% to 2% over 3 years is a 1% absolute risk, which is clinically irrelevant, but is a 33% relative risk reduction, which sounds impressive.
- What’s the downside? What are the common and serious adverse reactions and what are the odds of getting hit by one?
I’m willing to bet that your provider will not be able to answer these questions.
Here are some of my top candidates for deprescribing:
- Statins (Lipitor, Crestor, etc): LDL cholesterol does not cause coronary artery disease and lowering it does not significantly prolong life. All these drugs have major side effects including muscle pain, brain fog, nerve degeneration and heart failure. The major risk factor for heart disease is the metabolic syndrome and type 2 diabetes, both of which can be reversed by a proper diet.
- Insulin and other medications to lower blood glucose: Most cause weight gain, which worsens the underlying disease (metabolic syndrome). Getting off these agents is possible through the dietary reversal of the metabolic syndrome. Discuss with your primary care provider; our TWC doctors can help.
- Blood pressure medications: Prescription of these is heavily guideline-driven and based on office measurements of blood pressure, which are frequently elevated due to stress. Always monitor your blood pressure at home and keep a log. Current “targets” for “optimal” blood pressure are absurdly low, and produce serious side effects, especially in the elderly. Arteries do stiffen with age, so pressure must increase to maintain the perfusion of organs and tissues. Most hypertension these days is either stress-related or due to metabolic syndrome. Both are better managed by a non-pharma approach. Blood pressure medications should be tapered slowly under the guidance of a physician; our doctors will be able to guide this process.
- Bone medications (Fosamax, Reclast, Prolia, others): All these drugs block key cells that help bone to remodel and thus actually weaken bones long term. They have some horrific side effects. Just stop them, and try my Bone Formula.
- Psych meds: Narcotics, benzodiazepines, antipsychotics, amphetamine derivatives, such as ritalin, and antidepressants are heavily overprescribed and advertised. None have decent long term efficacy or safety data; all have major side effects including weight gain, diabetes/metabolic syndrome, and worsened suicide risk (SSRIs, such as prozac). These, unfortunately, must be tapered very slowly with the help of an experienced provider.
Deprescribing is an essential component in the restoration of robust health and wellness and is the embodiment of sound medical practice. Your Wellness Company physician can help lighten your pill burden.
Make it your top priority.
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About the Author:
Dr. Richard Amerling is a consultant Nephrologist/Internist with over 30 years experience. He specializes in diseases of the kidney, metabolic syndrome, diabetes mellitus, and hypertension. He is on the Chief Medical Board of The Wellness Company founded in 2022.
His areas of specialty include:
- Dialysis, including peritoneal and home dialysis
- Chronic kidney disease
- Metabolic syndrome
- Metabolic bone disease
- Guideline critiques
- Health care economics and politics