In April 2023, Netivot Shalom congregant Dr. Michael Steinman (Professor of Medicine at UCSF), discussed how scientists determine the benefits of medicines, common problems such as drug-drug interactions, and how to maximize the benefits and minimize the harms of medications. This blogpost summarizes his talk.
Dr. Steinman is a Professor of Medicine in the Division of Geriatrics at the University of California, San Francisco and the San Francisco VA Medical Center. A geriatrician-researcher, he cares for older adults in outpatient and inpatient settings and conducts research evaluating how older adults use medications, the problems that arise from medication overuse and misuse, and strategies for improving pharmaceutical care for older adults. His research is funded by the National Institutes of Health and he is co-principal investigator of the US Deprescribing Research Network, Associate Director of the UCSF Pepper Center for Aging Research, and co-chair of the American Geriatrics Society BEERS Criteria of Potentially Inappropriate Medications in Older Adults.
Rena Dorph, PhD: In Jewish tradition, respecting elders (kibud zekaynim) is a value that emphasizes the importance of honoring the wisdom of past generations. The Torah instructs people to “honor the elderly” (Leviticus 19:32). In the book of Job we learn “with age comes wisdom, and length of days brings understanding” (Job 12:12). The Hebrew word for “elder” (zaken) is used to describe someone who is both of advanced age and holds wisdom and experience. Overall, Judaism views elders as leaders and repositories of knowledge, and believes that they have much to share with the next generation.
Dr. Michael Steinman embodies the value of kibud zekayim. As a professor with UCSF’s Department of Geriatrics and a practicing geriatrician for UCSF and the San Francisco VA medical center, Dr. Steinman’s work responds to the call in the poignant prayer in the Yom Kippur liturgy “Do not cast us aside in old age, and do not forsake us when our strength fails.” As a member of our community, Mike shares his care and expertise with many of us. We are grateful that he agreed to be one of the featured speakers of this series.
Michael Steinman: In order to understand what we know about medications, it’s important to give you some background about how we systematically study the effects and side effects of medications. Randomized controlled trials consist of grouping people together of similar backgrounds. These people all need to have experiences and symptoms that are like one another. They are then split up, with half given the drug that is being tested, and the other half not given a drug. This method is used to see if the drug works on specific groups of people by seeing the difference in the progression of symptoms or other outcomes of the disease of interest of the two groups. It is often the case that the effect of the medication is very small. Something called the absolute risk reduction is the statistic that explains if there was a real impact of the medication. This statistic is easy to see when graphed, as it is essentially the difference in the two groups’ outcomes. For example, if you give intensive therapy with an effective drug to 100 people, there won’t be many deaths within 4 years. Of the 100 people, let’s say seven of them would die in the normal treatment, as opposed to the 5 people who would die in the aggressive treatment. This is a difference of 2%.
That 2% may not seem like a lot, but it definitely is something. It is often framed as a large amount by using a zoomed-in data set or graph. When zoomed in, the smaller difference is perceived as larger by the viewer as the gap between the lines is bigger compared to the graph than if the whole graph was in view. This particular study was done about intensive blood pressure reducing drugs among older adults (aged 80 and older). There are not many studies on this topic for this age group, making it important to get any kind of data/information about it.
Such a graph may show that there are no real changes before the 2 year mark of being on the treatment. This lack of “quick change” is because it may take time for the drug to start having a beneficial effect – for example, reducing the chance of dying that would otherwise be expected for the disease of interest. Over time, the slower progression adds up and it is reported as different levels of their outcomes (for example, rates of death or severity of symptoms) from those with less intensive treatments. It is also important to note that since in this case the difference is only 2% between the two types of treatments, most people won’t have any difference in the outcome of theirs with one or the other treatment – in other words, most people will still be alive after several years whether or not they take the drug, and some people will die over this time period whether or not they take the drug. A part of this is because of the fact that a study drug only affects one aspect of people’s health, and many other factors that are not affected by the drug can affect what happens to them. The participants in the study, while having similar experiences and treatment paths as one another, live different lives. It is important to recognize that the benefits of the different things someone does are cumulative. A single thing can make a difference, but the combination of many things at once may make a big difference.
Problems people can have with their medications
Every drug has its risks and its benefits, and the intensity of each of those is different for everybody. To figure out what the “expected outcome” would be requires different people taking the medication accounting for everything about them including (but not limited to) their age, other medications, genetics, sex, etc.
Statins are medications that affect cholesterol levels in your body, usually used to lower the “bad cholesterol” and raise the “good cholesterol” levels. The way that statins are prescribed has changed over time. It used to be that your dose would be completely personalized with the goal being to get your LDL below 100. It is now often the case – at least in part – that a certain dose of statin is the goal based on your risk and that there are set options for doses (low, medium, or high). There have been questions about if they affect your brain cells and lead to dementia, but studies have not affirmed that theory. PCSK9 inhibitors are also used to help cholesterol levels. These inhibitors are very expensive and injectable (unlike statins), and are used if someone can’t tolerate statins.
Using something like a symptom graph is very useful in figuring out if medications (like statins) are causing side effects in people – or if a drug is helping to reduce symptoms. Such a graph has its ups and downs, but has a general middle ground of “feeling normal.” If someone is having a bad day, their pain will be higher than on a good day. People usually go to the doctor when they have a spike in their symptoms, for example when their pain is high. If the doctor then starts a pain medicine and the pain subsequently improves, the patient may think that it was the new drug that caused the reduction in their pain. However, this reduction in pain may in fact just reflect the normal ups and downs of their pain symptoms, and may have nothing to do with taking the new medication.
There is a cycle to symptoms that makes it hard to distinguish between the positive and negative outcomes of a medication. A single medication can make a person feel better in some areas, and worse in others. It is also common that someone starts a medication and never stops, despite not needing it anymore. This could cause someone to still get the negative side effects of the medication without benefiting from it at all.
Practical things you can do to help your treatments
A way to see if the symptoms you are feeling are because of one (or more) of the medications you are taking would be to try being on and off of it to see if that helps you feel better/worse. It is important to talk to your doctor to inquire before taking that step, but it could be better to investigate removing a medication before adding more medication on top of your current ones. It is also helpful to keep a log of your symptoms so you can see patterns. This could help you see the spikes and drops of your symptoms to see if it seems consistently related to your medication or to an unrelated situation. You can also preemptively stop taking medication to avoid overmedication, in consultation with a healthcare professional. Do not do this without talking to such a person. If you have been taking a medication for a long time it is possible you don’t need it anymore. If it turns out you don’t need it anymore, it may be that you should stop taking it after having a discussion with a healthcare professional (for example, your doctor or nurse practitioner).
Geriatrics is a fairly new practice of medicine with a significantly smaller number of geriatricians than there should be to meet the number of older adults. Doctors have varying levels of knowledge on the subject. It is important to note that even if a doctor treats a lot of older adults, they don’t necessarily know a lot about how to provide optimal care to older adults. A good question to ask your doctor would be “What kind of training have you gotten in the care of older adults?”.
There are some particular resources that are helpful to older adults. Medline Plus has balanced information giving you answers to your inquiries. Health in Aging has common questions answered, as well as things you can do to improve the way you take medications. There is a lot of work to still be done in researching deprescribing.
(This post is part of Sinai and Synapses’ project Scientists in Synagogues, a grass-roots program to offer Jews opportunities to explore the most interesting and pressing questions surrounding Judaism and science. This is a summary of an event held at Congregation Netivot Shalom in Berkeley, CA in April 2023.)
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