Are you taking too many pills?

mum and dad

CAPTION: My seventy-something parents – were they taking too many pills?

I’ve been writing about the growing problem of polypharmacy – put simply that means taking multiple daily prescription pills for long-term chronic conditions. You can read the full article here in the Daily Mail’s Good Health section

I got the idea for the story after my lovely parents (pictured above) who are both in their mid seventies, came to stay with me with a rucksack jam-packed full of their prescription medication. I was shocked when I saw how many tablets they had been instructed to take. Admittedly, they do both have long-term chronic health conditions including diabetes, heart disease and arthritis – but what I was surprised at was how many additional pills they were taking to counter side effects of other tablets. Also some of the drugs they had been on for years and no-one had ever mentioned coming off them or reviewing the dose. It seemed to me that once you started taking a drug that was it and you were on it for life. I wouldn’t have worried but they’d both been complaining of non specific health problems including mental fogginess,fatigue and muscle pain and never really got a satisfactory explanation for them. They were just putting it down to old age.Then I started wondering whether drug interactions might be to blame for their symptoms.It had to be at least a consideration surely?
The polypharmacy debate
The truth is that no-one really knows the long-term effects of being on multiple pills for years and years. Dr Chris Fox, an old age psychiatrist from the University of East Anglia, who has carried research on the cumulative effects of commonly prescribed drugs, says he was always taught that if you take more than three drugs at time you will get a drug interaction. The trouble is these days lots of elderly people are taking a daily cocktail of prescription pills to treat medical conditions, prevent others and increasingly, to deal with the side effects of prescribed medication. Dr Fox says the effects of this have never been studied in large trials. In drug trials the patients selected are generally younger and not on medication for other conditions.
The annual number of prescriptions has increased from 11.9 per head in 2001 to 18.3 per person in 2011 in England and Wales. Most of this increase has been in prescribing in the over 65s. Almost half the elderly population have three chronic health problems including arthritis,diabetes and high blood pressure.It’s now quite common for this age group to be taking eight to 12 different pills daily.
Dr Fox’s own research has suggested that commonly prescribed anticholinergic drugs used for treating movement disorders, depression, incontinence and chronic obstructive pulmonary disease – can be associated with cognitive decline. I find this worrying (and so does he).
Too much of a good thing?
Dr Trisha MacNair a specialist in medicine for the elderly at Milford Hospital,Surrey, says a big part of her workload is working out whether patients admitted are suffering from an illness or drug interactions.
One review published by the University of Sydney of nine studies where elderly people had been taken off medication concluded that between 20 and 85 per cent of patients taken off blood pressure pills had normal blood pressure and did not need to go back on the pills and there was no increase in deaths as a result.
An Israeli study conducted by Dr Doron Garfinkel found 88 per cent of elderly patients in a study who were taken off some of their medication reported a global all-round improvement in their health.Only two per cent had to restart their pills because of a recurrence of symptoms and there were no adverse events or death attributable to the discontinuation of their drugs.
CAPTION: Millions of elderly people are taking multiple daily pills for chronic conditions
The cascade of prescribing
Take statins (prescribed for lowering cholesterol)as an example. You could suffer muscle pain as a side effect and be prescribed a non steroidal anti-inflammatory painkiller, which in turn could cause gastric problems. This could then result in you requiring a proton pump inhibitor (PPI) prescription (omeprazole for instance – there are currently 2.6 million prescriptions a year for this one PPI alone).
And so it goes on and on. Easy to see how the so-called cascade of prescribing can happen isn’t it? And doctors are probably only following the guidelines so doing nothing wrong – the problem is there are so many clinical guidelines for each condition these days. Another problem is that a patient might be under lots of different specialists too and communication between doctors isn’t always great – so no-one is looking at the whole picture. Patients might also be taking over the counter medicines and herbal remedies too – not realising they can also interact with their medication.Nightmare.
What to do for the best
Dr Fox advises that anyone on more than five daily pills needs to have a prescription review ‘at least once a year’ and that no-one should be left on drugs without one. He suggests you should ask your GP or community pharmacist for a prescription review and discuss any drug side effects with them. He stresses of course that you shouldn’t stop taking any drug suddenly or without medical advice.
And my parents? Well, they came off their statins and had some other dosages reviewed and feel much perkier. Dad’s muscle pain, fatigue and mental fogginess have all gone away and he now walks two miles a day and watches his diet to keep his cholesterol down instead. My mother’s health has improved too – not so markedly – but she has more chronic conditions. Both say they no longer feel drugged up to the eyeballs though.


Why gout is no laughing matter

CAPTION: Beer drinking is linked to gout – but it’s not the whole story

This article is all about gout. Yes,that funny disease that causes an inflamed, painful, big toe – you know the one. It’s hilarious – you get it from overdoing the booze and eating too much rich food – so it’s all self-inflicted and you don’t deserve any sympathy. Well, at least that’s the popular perception of it anyway.

By this point you’re probably sniggering about gout being something boozy hedonists suffer from. And yes, you’ll have that portrait of Henry VIII th popping up in the popular stereotypes hemisphere of your brain. You know the one – where he’s looking portly and middle-aged with a pot belly, a haunch of venison on a gold platter and a goblet of fine wine in his hand.


CAPTION:Does a Henry VIIIth style diet really give you gout?

Yes, most of us think gout is a joke – although quite why and at what point in history this was decided I’m not sure. I’m pretty certain though most gout sufferers have not been spreading that particular rumour – such is the agony they suffer. Doctors say a gout attack is the most painful thing a human can live to tell the tale about – bar childbirth and kidney stones that is.
But gout is actually no laughing matter; it’s a form of arthritis caused by high concentration of uric acid in the blood. This leads to the formation of tiny needle like crystals in the joints and kidneys (where they form kidney stones) and less commonly in other parts of the body including the spinal cord and the vocal chords.Gout is as painful as rheumatoid arthritis – but does anyone laugh when you say you’ve got that? Exactly.

Why gout can be so serious
If left untreated or uncontrolled gout can form chalky lumps called tophi, which can severely damage joints, making walking and using the hands extremely painful. In extreme cases joint replacements and even amputation is necessary (although the latter is virtually unheard of).
The serious complications of gout hit the national news headlines in January when it was revealed that Mark Cahill ,52, the UK’s first hand transplant recipient needed a new hand because his old one had been destroyed by gout.
But even when the-gout-is-serious message gets across – there’s still this misconception that gout is entirely self-inflicted and just down to an appetite for booze, steaks and oysters. In fact, although a diet rich in purines – proteins found in foods such as red meat, offal, seafood, shellfish,alcohol, (particularly beer)and vegetables including cauliflower and lentils – can raise uric acid levels in the blood and lead to crystal formation in the joints – it’s not the whole story. Gout is actually down to how your body processes and eliminates uric acid from your body and not on how much rich food you eat. In people who don’t suffer from gout – eating purine–rich foods can raise uric acid levels but their kidneys are efficient at eliminating it from the body in urine. People with gout actually have a defective mechanism for eliminating uric acid from the body – and this is thought to be a genetic predisposition

CAPTION: Red meat is rich in purines

Funny and self-inflicted
When I was interviewing gout sufferer Neil Pert for this feature I wrote for the Daily Mail Good Health section
section this week, he told me the worst aspect of coping with the disease is the sneering and sniggering he has to put up with from others. ‘They think gout is a big joke,’ Neil recalls. ‘My doctor seems to feel its all self-inflicted too, but I haven’t touched booze in eleven years and follow a strict diet – to avoid purines which can break down into uric acid and cause gout. I avoid red meat, offal, seafood, shellfish, oats and a whole host of other foods to try to control it.’

Unfortunately though, Neil, a postman, now has daily joint pain in his feet and has had to transfer to a desk job and is worried about his long-term health. His doctor did offer him treatment with a drug called allopurinol – but he didn’t like the sound of the side effects and tried to control his uric acid levels with diet alone.Despite losing six stone in weight though (down from nearly 23 stone) – he now has joint pain in his feet and elbows.

CAPTION:Gout can affect any joint but an inflamed big toe is the classic symptom

Gout destroys joints

Neil’s situation is typical of how gout can if left untreated or under controlled can then destroy joints. Professor George Nuki medical adviser to the UK Gout Society though says joint damage is entirely preventable if uric acid levels are controlled by drugs but the condition can be poorly managed.
The main drug for preventing gout is allopurinol which works by reducing uric acid levels in the blood by blocking the activity of the enzyme that converts purines to uric acid. GPs are supposed to start patients off on a low dose and then gradually adjust it upwards until blood tests reveal that uric acid levels have been reduced to such a level that the crystals dissolve and new crystals stop forming. But research has revealed less than 10 per cent of patients receive the follow-up blood tests – so many people stay on the low dose that does not reduce their uric acid levels sufficiently and crystals continue to grow and can damage their joints.
If patients can’t tolerate allopurinol(possible side-effects include skin rashes, headaches, indigestion and diarrhoea), or they can’t be prescribed it because they have kidney problems, the alternatives include febuxostat – which acts in the same way but is broken down by the liver instead of the kidneys – and benzbromarone, which works by stimulating the kidneys to excrete uric acid.

Dr Alex Brand , consultant rheumatologist at the Chelsea and Westminster Hospital and the private Lister Hospital says joint damage from gout can be very severe .’It can make walking difficult and painful and severely limit the use of the hand. Very elderly people tend to have reduced kidney function and higher uric acid levels. Certain drugs such as diuretics and other drugs used to control blood pressure as well as aspirin – which are commonly prescribed in the elderly can also raise uric acid levels.’
New treatments
When it comes to treating tophils, this used to involve surgery, ‘but this is rarely necessary these days because aggressive management with high doses of drugs can dissolve them,’ explains Professor Nuki .Krystexxa (peglioticase) is available for patients with severe, disabling gout which has caused joint damage, who have failed to respond to other drug treatments, on a case by case basis only in the UK. The drug hasn’t yet got a licence from the European Medicines Agency, however in October (2012) the EMA issued a positive opinion – seen as the first step towards this.

Charles Dickens
Charles Dickens

CAPTION : Charles Dickens was also plagued by gout

Neil’s message to you

Neil Pert worries about his future. He says:’Perhaps diet alone is not enough and I do need drugs as well after all – I just didn’t have enough information. I’m really worried about what is happening inside my joints now – I don’t want to end up in a wheelchair or heaven forbid having an amputation.
‘I also want people to know that you don’t have to have a Henry VIII th style lifestyle to get gout. It certainly isn’t funny. People just don’t realise how serious and painful gout can be.’

Here’s another article I’ve written about gout that you may like to read



You’ve been told you have IBS but could you have BAD ?


CAPTION: Always on the loo?

Until a few weeks ago I’d never heard of bile acid diarrhoea (let’s call it BAD). Despite writing about all manner of tummy upsets for quite a while now – including Irritable Bowel Syndrome (IBS), Crohn’s disease and ulcerative colitis to name but a few – I’d never come across this particular gut nasty.
But then I spoke to Professor Julian Walters, professor of gastroenterology at Imperial College, London, and learned that up to 500,000 people in the UK who have been diagnosed with Irritable Bowel Syndrome – may actually have BAD instead.
Why does it matter? Well, according to Professor Walters, BAD is comparatively easy to treat and there’s a diagnostic test and effective medicine you can take for it – where as the diagnosis and treatment for IBS is far more complicated and seems (to a layman like me at least) to be a more let’s suck-it-and-see-if-it-works approach.

Why don’t more people know about BAD?

I can’t be the only one who is wondering why BAD is not on the radar of more doctors(and patients). By contrast, coeliac disease has become fairly well-known now as has Crohn’s disease. But BAD affects potentially far more people, so why is there is no information about it?
‘Most patients – and doctors – are unaware that bile acid diarrhoea even exists and that there is a diagnostic test and effective drug treatment available,’ explains Professor Walters.
‘IBS is estimated to affect four million adults in the UK; of those 1.3 million have diarrhoea as the predominant symptom. However, its cause is often difficult to diagnose and patients may undergo several investigations, including those for inflammatory bowel disease, colonic cancer, coeliac disease and chronic infections, without a definitive cause being identified or effective treatment.’

Freedom after 48 years

Judith Fulton who I interviewed for the Daily Mail Good Health section suffered from unexplained daily bouts of watery diarrhoea for over 40 years. She had countless tests including the invasive kind most of us would rather avoid if it isn’t absolutely necessary – doctors just said it was IBS though -and they offered her no treatment.
When Judith read about Professor Walters’ research though it was a light bulb moment and she tracked down his email on the internet and asked him for a consultation. She was later diagnosed with BAD and after treatment with the drug cholestyramine (Questran) her symptoms disappeared within a few weeks. After forty-eight years of suffering she is now free to leave the house without researching where the nearest toilet is. That’s what I call a result and partly why Judith was willing to be interviewed about such an embarrassing health problem – she wants more of us to know about it.

A bit about bile acid (before we go on)

I won’t bore you with a full blown biology lesson, but in a nutshell: bile acids are essential for digestion and absorption of fats and fat-soluble vitamins in the small intestine. The liver produces large amounts of bile acids which flow into the intestine every day, but only relatively small quantities are lost from the body. This is because approximately 95 per cent of the bile acids are recycled back to the liver from the ileum (part of the small intestine). But in bile acid diarrhoea – bile acid is overproduced and the excess bile passes into the colon causing watery diarrhoea.
Bile acid diarrhoea is also associated with Crohn’s disease, a chronic severe condition characterised by inflammation, ulcers and bleeding that may affect any part of the gastrointestinal tract, including the terminal ileum (the end of the small intestine). This is because Crohn’s causes inflammation and reduces absorption of bile in the intestine and this sometimes necessitates removal of the ileum. This is referred to as bile acid malabsorption as bile is not as absorbed as well in the intestine.
‘In idiopathic bile acid diarrhoea though – patients don’t have a problem with absorbing the normal amounts of bile produced, explains Professor Walters.’Their diarrhoea is triggered by a hormone disorder which causes overproduction of bile and it is this excess bile which causes the diarrhoea – this is an important distinction,’ explains Professor Walters.

CAPTION: Bile acid is produced in the liver

Hormone deficiency is the cause

Professor Walters conducted research which found that the trigger for idiopathic BAD (from an unknown cause not related to Crohn’s disease) is a deficiency in a hormone called FGF19, which normally switches off bile acid production when bile acid is reabsorbed.
‘At the moment we don’t know why this happens – it doesn’t appear to be genetic although some patients report their symptoms started after a gastrointestinal infection.’

Unfortunately the symptoms of BAD can be hard to distinguish from diarrhoea caused by IBS.These include up to ten watery bowel movements every day, usually with an urgent need to go and frequently resulting in accidents or faecal incontinence. There is also some bloating and abdominal discomfort.

Diagnosis and treatment

Unlike IBS though, there is a diagnostic test available for BAD. It’s called the SeHCAT test(which stands for selenium-labelled synthetic bile salt) and involves two full body scans seven days apart. In a person with normal bile acid production more than 15 per cent of bile is detectable in the body after seven days, but in people with BAD this figure can be as low as one to five per cent.
Once diagnosed with BAD patients can be prescribed cholestyramine and around two-thirds of patients are reported to respond – although this admittedly may take some time until the correct dosage to control symptoms is found.
CAPTION: What’s really causing your upset tummy?

Hang on a minute though…..
As with many things in medicine though, not everyone agrees. The National Institute for Clinical Excellence, for instance, recently decided although it was’promising’ there was insufficient evidence to recommend the SeHCAT test. Professor Carole Longson, NICE health technology director, said there was also little evidence of the clinical effectiveness of the drugs used to treat the condition and also whether bile acid diarrhoea is a primary or secondary condition.

Professor Nick Read,a gastroenterologist and adviser to the IBS Network is somewhere in between the two camps. He doesn’t believe BAD is a medical condition in its own right – just a symptom of IBS diarrhoea, but on the other hand he says he prescribes cholestyramine frequently to people with IBS where diarrhoea is their predominant symptom and it works really well. He told me:’I find that cholestyramine is an effective drug which mops up bile acid in the intestine. I’ve seen patients who have had diarrhoea for years dramatically improve using this treatment.’

Whatever the mechanism – the upshot is if you’ve had diarrhoea for years and been given an IBS diagnosis and told to live with it, you might want to ask about getting a SeHCAT test. Just like Judith the test (and the treatment) might give you your life back.

Watch Professor Walters here:


Here’s some more of my articles about gut health you may want to read.