We’ve been getting a lot of propaganda in the news about why docs should be using X medicine (an old one that works just as well) instead of Y medicine (a new one that costs a lot more).

Heh. Lots of us have used both medicines, and a lot of us rely on our clinical experience to guide our care, not on “metanalysis” type studies that combine several studies (that often have a bias) to prove a point.

The implication behind a lot of these articles is that doctors are mindless zombies who read advertisements and obediently prescribe these medicines (earth to outerspace: I never read those fancy ads in the medical journals, and most of us take the drug salemen information with a grain of salt).

You know, sometimes the cheaper medicines work as well, but sometimes we use the fancy newer drugs for a reason.

Take the study that insists doctors treating high blood pressure need to start with the thiazide diuretic as the first line medicine.

The real reason for this can be found in this article:

Our analysis indicates that there is a substantial potential for savings if thiazides were used as first-choice drugs in the treatment of uncomplicated hypertension. …. In the US, for instance, the potential drug cost savings may be over US$1 billion.

So why do docs insist on using the more expensive Calcium channel blockers (e.g.Amlodipine) or ACE inhibitors (e.g. Lisinopril or the ACE2/ARB types e.g. Losartan)?

It’s the side effects, stupid.

Even the above study found that 20-30% of folks stopped using the diuretic.

Dr. Davis’ article here has the “bad news” about side effects. Thiazide diuretics result in Potassium loss, leaving some folks weak. They also raise your blood sugar and bad cholesterol levels a little bit. And they raise your uric acid level, meaning if you have gout, you might end up with more attacks.

But the dirty little secret why patients don’t like these medicines is that it makes some folks have to run to the bathroom more often: which can be a problem if you are in the mall or at the senior center and the bathroom has a line.

But for male patients, the reason we avoid it is this: impotence. Studies show that 3 to 30 percent of men are affected.

A recent scare article in the Huffpost by an author connected with a Health magazine does bring up some good points about the problems of mineral depletion by the thiazide diuretics.

these diuretics are also known to deplete other minerals, such as magnesium, sodium, potassium and zinc, which are seldom specifically supplemented. One study found hypokalemia (low potassium) in 8.5 percent of people treated with thiazide diuretics and hyponatremia (low sodium) in 13.7 percent in the same patient population.2,3) This indicates the importance of testing levels, and not simply restricting sodium…

She goes on and on, and of course recommends you take lots of supplements of vitamins and minerals which are probably advertized in her magazine.

Yet that doesn’t mean she doesn’t have a point. Low potassium was a common problem with the higher doses used in the past, and continues to be a less serious problem. And low potassium makes one feel “as weak as a dishrag” (as one of my patients put it).

Yet for some patients (mildly obese patients with high blood pressure and fluid retention) they are the drug of choice.

And for many patients, a small dose helps bring down the blood pressure, so we often add it with our other blood pressure medicines.

And if you have congestive heart failure, they are a good choice, although we often use the stronger loop diuretics (e.g. Lasix/furosemide) in these cases.

In summary, take every “ain’t it awful” article with a grain of salt. (heh…salt increases blood pressure too).

Every medicine has side effects, so be skeptical of claims that treating mild cases of some disease saves lives.

Like most docs, I shuddered when drug companies pushed their “new” expensive pills directly to patients, when we docs knew the older ones worked fine (e.g. Vioxx, Celebrex work no better than Tylenol or Ibuprofen).

But now, with the government taking over health care, expect a push to use the older medicines for cost containment.

Now, when I was in private practice, few of my patients had insurance to cover medicines, so I am aware of the price problems. But sometimes a more expensive medicine is worth it.


Nancy Reyes is a retired physician living in the rural Philippines. She blogs at Finest Kind Clinic and Fishmarket.

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