Doctor, do I have to take this medication forever?
Some people have hypertension only at times of great stress. Monitoring your own blood pressure can help pinpoint when meds are needed, and when they re no longer necessary. (Fotolia.com / May 8, 2013)
Who would want to take a medication every day unless there was a very good reason to do so? Do we have alternatives that actually are effective? Can we take medications just until other measures become effective? These are important questions that are studied in carefully controlled clinical trials. The results allow us to answer many of these questions based on data (evidence-based medicine).
High blood pressure (hypertension), diabetes, heart rhythm problems, and congestive heart failure are examples of potentially deadly diseases that may best be treated with medications taken every day. Drugs to reduce high cholesterol levels or chronic aspirin therapy are examples of proven interventions that decrease the likelihood of damaging or fatal illnesses in some situations.
Luckily, evidence-based medicine also has shown that for some people there are effective ways to avoid medications or to phase out the need for medications. Here are some examples:
1. High Blood pressure (hypertension):
Sustained high blood pressure puts abnormal strain on your heart and arteries and can lead to heart attacks (myocardial infarction), heart failure, strokes, and kidney failure. Treatment can greatly reduce the risk of these problems. Most hypertension is caused by a genetic predisposition and /or stress. Hypertension often runs in families.
Our goal is to keep the blood pressure less than 140 (the peak pressure in your arteries after the heart contracts)/90 (the lowest blood pressure between cardiac contractions). Some reports indicate a systolic blood pressure reading (the top number of the reading and the measure of blood pressure when the heart is beating) of 130 may be pre-hypertension, but we're not yet certain if medications are needed.
Systolic blood pressure over 130 should make you aware and to begin to take steps to deal with your blood pressure. When it does come time to treat hypertension, several kinds of medication can be effective.
Often, there are generic drugs, relatively inexpensive, that are effective. You can monitor your own blood pressure at home to make certain the medication is effective. Since we have many choices for blood pressure medication, there usually are effective alternatives if you have troublesome side effects.
If your blood pressure is elevated, your doctor may recommend a medication to control it. Reducing salt in your diet can help. Losing weight, stress management, and exercise also will give you a chance to avoid or reduce the need for drugs. Some people have hypertension only at times of great stress, requiring treatment only for that brief stressful period. Monitoring your own blood pressure will help determine when medication is needed, as well as when medication no longer is necessary.
2. Diabetes (diabetes mellitus, high blood sugar)
Juvenile diabetes usually results from destruction of the beta cells in the pancreas that produce insulin. This can be a fatal illness unless insulin is given to control the blood sugar. Diabetes requiring insulin can occur at any age.
A more common form of diabetes is related to diet and being overweight. Your pancreas may begin to fail and not be able to produce enough insulin. When we start this group of patients on medication, they want to know if it's forever.
We can now reliably tell them that weight loss and exercise may restore normal blood sugar control. In fact, large scale studies involving thousands of patients have shown that lifestyle changes (diet, exercise) over time can be more effective than medication alone.
Medications usually can keep blood sugar at safe levels, but controlling sugar metabolism with diet and exercise is very important and may be sufficient to eliminate or avoid the need for medication.
3. High cholesterol
High levels of some forms of cholesterol in the blood increase the risk of damage to arteries and therefore the risk of vascular illnesses, such as heart attacks, strokes, and proper blood flow throughout the body. Studies have documented these risks, as well as decreased risk of vascular disease when the cholesterol is controlled.
When there's a strong family history of vascular disease, diabetes, or established vascular disease, regardless of the cholesterol level, you need a medication to lower your cholesterol level. In these cases, even if your cholesterol is in the normal range, it may be abnormal for you and the association of progressive vascular disease is much too high. Lifestyle change is still of great added benefit.
Diet, weight loss, and exercise can be very helpful or even can eliminate the need for medication in people with none of the serious risk factors.
When gastric bypass patients lose a lot of weight we often can reduce or eliminate medications for hypertension, increased cholesterol, and diabetes.
4. Palpitations (rapid or irregular heart rate)
Persistent or episodic rapid heart rate or irregular heart rate can indicate the presence of serious disease or can be annoying, but harmless. Persistent or episodic heart rhythm problems usually should be assessed by a physician.
There are many different types of harmless but troublesome rhythm disturbances that cause palpitations. Among the most common is the sensation of the heart pounding. This often is associated with a somewhat elevated heart rate between 120 to 140/minute. These occur most often in young women.
The second most common complaint is episodes of "fluttering" lasting 3-4 seconds at a time, with no dizziness or shortness of breath. These usually occur when the person is lying quietly in bed or watching TV late at night. These seem to affect both men and women evenly.
These benign events can be controlled by medication, but these treat the symptoms. There are some things a person can do to manage this problem themselves: cut back on caffeine, or at least cut down. Coffee, tea, many soft drinks, "power" drinks, some sports rehydration drinks, some chocolate products, some ice creams, some chewing gums, some candies, and other commonly used foodstuffs contain caffeine.
Also, watch out for oral decongestants, such as pseudoephedrine, present in many over-the-counter allergy medications, and in some prescription allergy medications. Vasoconstrictor nasal sprays sometimes can cause palpitations. If you can't cut down, and the palpitations are found to be harmless, be prepared to ignore them.
5. Congestive heart failure:
When the heart is unable to pump blood efficiently, congestion builds up in the lungs, in the rest of the body, or both. Shortness of breath, decreased exercise tolerance, difficulty lying flat to sleep, and swelling of the ankles can be manifestations of heart failure.
Congestive heart failure can be mild, but is a potentially fatal problem. There are many causes and several medications that are known to be effective, depending on the cause and the individual's situation. Development of congestive heart failure should trigger careful assessment of possible causes or contributing factors, and careful assessment of the success of therapy.
The mainstay of treatment is diuretics, medications that help remove accumulated fluid from the body. We also can use medications such as ACE inhibitors (drugs that inhibit the angiotensin converting enzyme that generates angiotensin that in turn can have undesirable effects in heart failure patients) and beta blockers (drugs that block some actions of the body's own epinephrine and norepinephrine).
Diuretics, at least initially, cause increased amounts of urine in people with congestive heart failure and fluid accumulation. This can be disruptive day and night. Naturally this leads the person to ask, "Do I have to take these diuretics the rest of my life?" The answer might be yes, but in some patients avoiding excessive fluid intake, or fluid intake late in the day, can limit urinary frequency.
Low-dose aspirin therapy has been shown to reduce the risk of heart attacks and strokes in some patient groups. Your physician can assess the value of daily aspirin therapy based on family history, blood pressure, cholesterol levels, smoking history, diabetes, and other factors that influence the benefits and also the risks of low dose aspirin. If you do need aspirin, that means forever to decrease the risk of a heart attack or a stroke.
Aspirin is not for everyone. It increases the risk of bleeding, although the risk is small. At this time, there's not enough evidence to say the benefits outweigh the risks for every adult to take aspirin to guard against heart attacks or strokes.
There are many examples of medical situations in which daily medications may be crucially important. In some situations however, changes in lifestyle can minimize or eliminate the need for meds. Knowing when and how to modify lifestyle factors and/or medications under the care of a physician can help patients with these problems regain and maintain a healthier life
(Yale M. Samole, M.D., FACC, is board certified in cardiovascular disease, internal medicine and nuclear cardiology. He has been practicing for more than 40 years and is currently with Baptist Health South Miami Heart Center.)
(WhatDoctorsKnow is a magazine devoted to up-to-the minute information on health issues from physicians, major hospitals and clinics, universities and health care agencies across the U.S. Online at http://www.whatdoctorsknow.com.)