Risedronate and Etidronate both effective for treating corticosteroid-induced osteoporosis

A 12 month, double-blind, placebo-controlled, randomized, multicentre study by Jencen and colleagues demonstrated that 5 mg/day of risedronate (Actonel) given for twelve months was effective in significantly increasing bone mineral density and lowering the risk of vertebral fractures, for patients on chronic corticosteroid therapy. From the abstract it is unclear if these fractures were clinically symptomatic, radiologically detected, or both. Risedronate prevents bone loss by inhibiting bone resorption. It represents a new type of biphosphonate which is hoped to have less gastrointestinal complications than other bisphosphonates, however, residronate is not available in Canada at this time.

Adachi and colleagues pooled results from two similarly designed, randomized, double-blind, placebo controlled trials examining the effectiveness of Etidronate (Didrocal) (which is available in Canada). Intermittent cyclical therapy with etidronate in patients recently starting corticosteroids proved to be effective in preventing bone loss in men, pre- and post-menopausal women. This data supports previously published studies employing a bisphosphonate to decrease the loss of bone mineral density with chronic systemic corticosteroid use.

Abstracts are available at http://ex2.excerptamedica.com/98ac

Combining HRT and Alendronate better than HRT alone

Fifty one papers relating to osteoporosis were presented at the American College of Rheumatology meeting in November 1998. One study by Lindsay and colleagues demonstrated that adding alendronate (Fosamax) to ongoing hormone replacement therapy (HRT) in women with postmenopausal osteoporosis provides significant increases in bone mineral density at the lumbar spin, hip and femoral neck. The study also found that adverse drug reactions were not significantly different in the Alendronate HRT combination group when compared to HRT and placebo. The combination was well tolerated. The study is targeted to be published by May 1999 in the Annals of Internal Medicine. To date there are no large published randomized clinical trials of the addition of bisphosphonates to HRT or vice versa.

All abstracts from the meeting are available at http://ex2.excerptamedica.com/98acr

SSRIs No Safer Than Other Antidepressants

Thomas Tsirakis, BA

The use of selective serotonin reuptake inhibitors (SSRI) as a first-line of treatment for depression in the elderly has become the standard of choice in clinical practice. The widespread preference of initiating treatment with an SSRI versus the more traditional tricyclic antidepressants (TCA) has been largely due to the belief that SSRIs have a safer profile, are better tolerated, and have a lower drop-out rate than TCAs. An accumulating number of studies published in the last few years, however, have begun to question this rationale, and have demonstrated that SSRIs are neither as advantageous, nor as safe as previously believed.

There are four SSRIs currently available [fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox)], each possessing both similar and unique side-effect profiles. Though SSRIs have been the main-stay of first-line treatment in recent years, it is important to be aware that they are not without risk. The belief that SSRIs exhibit fewer side-effects than TCAs is misleading in that TCAs have been studied far more extensively than SSRIs, and nearly every study comparing an SSRI with a TCA has used one of the most poorly tolerated TCAs in the comparison, thus making the SSRIs look remarkably tolerable.

Are Canadian MDs Overprescribing Anti-psychotics in Nursing Homes?

Anna Liachenko, BSc, MSc

Although anti-psychotic medications produce substantial side effects in the elderly, these drugs are extensively prescribed in nursing homes. Nursing home studies conducted in the United States in the 1980s showed that anti-psychotics were often used to manage disturbing behavior that did not fall into the clinical definition of psychosis. In 1987, the use of anti-psychotics was restricted by the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA87). The reform spelled out the exact guidelines for the use of each anti-psychotic drug in the elderly, thereby substantially reducing the amount of prescribed medication in nursing homes. Whether Canadian physicians also overprescribe anti-psychotic drugs is not clear. At present, clinical studies are being conducted to estimate the extent of anti- psychotic use and to find strategies to safely reduce the amount of medication when possible.

Mental illnesses, dementia in particular, are often accompanied by behavioral disturbances. This is often the primary reason for placing the older person in a nursing home. Thus, the prevalence of behavioral disturbances in nursing home residents is high and is estimated to be close to 60%. Only 10% of these behaviors are psychotic, i.e. accompanied by "delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature" (DSM-IV).

Treating Arthritis: Try Cheaper Drugs with Less Side Effects

Neil P. Fam, BSc

Arthritis has been called the sleeping giant of Canadian health care. According to Statistics Canada, over 3 million Canadians suffer from osteo-arthritis (OA), with another 300,000 affected by rheumatoid arthritis (RA).¹ Together, these diseases represent one of the leading causes of chronic disability, lost productivity and worker absenteeism in Canada.² As our population ages, more patients are presenting to physicians with musculoskeletal complaints, most of which center around chronic joint pain.

Treatment of the pain of arthritis involves both pharmacologic and non-pharmacologic approaches. Traditionally, treatment of OA and RA has revolved around the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although these medications are often effective in relieving pain, they are associated with significant gastrointestinal and renal complications. Elderly patients are particularly prone to life-threatening complications such as GI bleeding and perforation. For these reasons, other treatment modalities are often utilized. This article presents an overview of pain management strategies, with a focus on OA, the single most common cause of arthritis in seniors.

OA pain

In the management of osteoarthritic pain in the elderly, the best approach is to begin with therapies that are inexpensive and have a low risk of side effects. The following is a stepwise approach, summarized in Table 1.

Seniors Seek Complementary Medicine for Chronic Conditions

David Yap, BSc

The area of complementary medicine in Geriatrics is important, as the use of complementary practices grows along with the expanding elderly population. Complementary medicine consists of a wide range of health care services, which are offered outside the mainstream of orthodox western medicine. Some types of complementary health services are: Acupuncture, T'ai Chi, Herbal Medicine, Homeopathy and Chiropractic.

In complementary medicine, health is viewed as the result of interactions between positive life building forces and negative destructive forces. To treat an illness complementary medicine attempts to improve the positive forces by incorporating a holistic conception of health. Complementary medicine lacks the emphasis on determining a specific pathophysiological diagnosis. The assessment of an individual is based on history and physical exam without a heavy reliance on laboratory tests to confirm a particular diagnosis. Lastly, in complementary medicine the individual actively takes part in their well being and is at least an equal partner in the practitioner-patient relationship.

It is important for family doctors and general internists to have a basic understanding and background in complementary medicine due to the increasing use of complementary services and the potential benefits.

Nicotine Substitution Aids Smoking Cessation

Michelle Durkin, BSc

According to the Addiction Research Foundation tobacco use is still considered Canada's greatest public health concern even though the percentage of cigarette smokers is declining. Approximately 35,000 Canadians die prematurely each year due to smoking.¹ Despite the increased risk of heart disease, lung cancer, emphysema and other health problems, patients are reluctant to stop smoking and attempts to stop often fail. This is because of nicotine, a naturally occurring alkaloid. It can cause both a physical and psychological dependence that can be compared closely with addiction to substances such as heroin and cocaine.¹

Nicotine in the Body

Nicotine is rapidly absorbed into the body through the respiratory tree, buccal membranes, as well as percutaneously. Once in the body, it will mimic the effects of acetylcholine at nicotinic receptors (see Figure 1). These receptors are found at autonomic ganglionic synapses of the sympathetic and parasympathetic branches of the nervous system as well as neuromuscular junctions. Due to the wide distribution of these receptors in the body, nicotine can illicit a wide variety of effects and can act as a stimulant or a depressant.

Nicotine Substitution Therapy

Although the majority of smokers want to reduce or stop smoking, attempts to do so often fail.¹ It is the powerful addiction to nicotine that can make quitting so difficult.

Drug Use in the Elderly--the Two Edged Sword

Barry Goldlist, MD, FRCPC, FACP

The issue of drug use in the elderly is extraordinarily important. All physicians know that medications in older patients are a two edged sword: the elderly have many more diseases that potentially benefit from medications, but they are also prone to more adverse effects from those same medications. The increased burden of disease in the elderly is the major reason for the high drug utilization in the elderly, but in the clinical practice of geriatric medicine, it is almost as common to see potentially beneficial medications withheld, as it is to see unnecessary polypharmacy. Of the many reasons for this, I would like to discuss two physician-related factors, excessive fear of side effects, and a flawed understanding of cost effectiveness.

There is no doubt that the elderly are prone to drug side effects. However, withholding effective treatment because of a fear of side effects is often an example of flawed reasoning. All treatments, regardless of the age of the patient, require that the risks and benefits are evaluated and a judgement regarding the balance is then made. To withhold anticoagulants from an elderly patient with atrial fibrillation because age increases the risk of bleeding is assessing only one side of the equation. The number of strokes prevented by anticoagulation is greater in older patients, and if anything the risk/benefit ratio is more favorable for seniors. Similarly, withholding anticoagulants because a patient has fallen once or twice, means a definite benefit is lost to prevent a theoretical complication of traumatic bleeding. Current evidence does not warrant the common perception that recurrent falls are an absolute contraindication to anticoagulation.

Many new pharmaceuticals are quite expensive, and there is a feeling among some physicians that they are too expensive for the elderly. While pharmacoeconomics is a crucial new discipline, none of the experts in the field would eliminate the elderly from potentially beneficial treatments. Decisions not to use expensive medications when cheaper efficacious therapies are available are an appropriate approach regardless of age. Once again, because of the higher event rates for the elderly, treatments are generally more cost effective in the elderly. The best example of this is the use of thrombolytic therapy in those over 70. The cost per life year saved is much less in the elderly than in younger patients with myocardial infarction.

In summary, we do want to avoid polypharmacy in the elderly, and the prescribing cascade that can result, as more drugs are prescribed to relieve side effects of prior medications. However, it is just as important to ensure that therapies of proven value are not withheld from older patients.

Government Squeezed to Decrease Approval Times

Shechar Dworski, BSc

Despite ongoing criticism, many consider the Canadian drug regulation process to be one of the most respected and effective regulatory approaches in the world. The legislation governing drug approval in Canada is under constant scrutiny and comparison with other leading countries, especially the United States. While critics have pointed out weaknesses, new initiatives have been placed to correct these deficiencies. Some critics claim that the process is too slow. Others rebut by saying that our system is much more scrutinizing and prove this by citing numerous examples of drugs (e.g. several vaccines) not given approval in Canada, that were approved and subsequently recalled in other countries due to adverse reactions. Despite the longer and more intense screening and approval process, critics state that post-approval monitoring in Canada is insufficient, and cite numerous examples of drugs initially approved, but later recalled in other countries due to deaths, to which the Canadian boards did not respond to in a timely manner. There are also claims that the drug industry's close proximity to drug legislative boards results in their own economic interests superceding the public's best interest. To understand the nature and reasoning behind these claims, a closer look at the drug approval process in Canada is needed.

Who are You Going to Call?

Eleanor Brownridge

Who does a patient call when wondering why a drug is not working, when concerned about an adverse reaction to a drug, or when hearing on the radio that green vegetables interfere with Coumadin?

Faced with absorbing so much verbal advice about their disease, diet, and life-style changes, it is no wonder that so many patients experience information overload. Once home and starting on a treatment, new questions arise.

Thirteen years of experience by the Medication Information Line for the Elderly (MILE) in Manitoba suggests that many older people are reluctant to call their physician with a drug-related concern for fear of being an economic burden to the healthcare system or just appearing foolish. They do not consult their regular pharmacist either because it did not occur to them that the pharmacist could provide such information, or because they thought the pharmacist was too busy.

Ruby Grymonpré, PharmD, associate professor at the Faculty of Pharmacy, University of Manitoba started MILE in January 1985, to fill a drug information gap for elderly consumers in Manitoba, many of whom are housebound or living in isolated rural areas. Funding for the annual $85,000 budget has come from Manitoba Health, University of Manitoba and individual drug manufacturers. Available weekdays from 9 am to 3 pm, MILE pharmacists log an average of 200 calls a month.