Mismedicating the elderly - says who? - Editorial

Journal of Family Practice, Oct, 1995 by August E. Miller, Jr.

Let's see now: one of the forbidden drugs is gone forever, two are no longer in the PDR, and five others are rarely prescribed. Only four of the remaining drugs made the current best-seller list, and of these, only Darvon finished among the top 50. Yet somehow, using this ragtag assortment of pills, doctors still managed to mismedicate a full one fourth of the over-65 United States population? Incredible!

Consider Persantine (dipyridamole), which by the researchers' estimates, doctors prescribed 4,832,889 times for elderly patients in 1994.[1] The Harvard researchers point out that as a blood thinner, Persantine is no better than common aspirin; its only legitimate indication is with warfarin in the treatment of patients with artificial heart valves. Here, they set the record straight: "Only 36,000 Americans (half of them older than 65 years) underwent valve replacement in 1987. Even assuming a long life expectancy, artificial heart valve recipients cannot account for many of the 1.8 million older people using dipyridamole in 1987."

What they fail to mention is that Persantine, also a vasodilator, was originally prescribed as an alternative to nitroglycerin. The FDA-approved indications for Persantine in the 1987 PDR reads thus: "Possibly effective for long-term therapy of chronic angina pectoris. Prolonged therapy may reduce the frequency of, or eliminate, anginal episodes, improve exercise tolerance, and reduce nitroglycerin requirement."[12(p717)] Contrast this with the FDA-approved statement in the 1988 PDR 1 year later and 1 year after the database: "Persantine is indicated as an adjunct to coumarin anticoagulants in the prevention of post-operative thromboembolic complications of cardiac valve replacement."[13]

Once the indications for Persantine changed, sales plummeted; 7 years later, no form of dipyridamole remains on the top-200 list. Make no mistake about it: physicians did not write 4.8 million Persantine prescriptions for the elderly in 1994! The numbers just don't wash. No drug ranked so low could possibly be used daily by 1.8 million senior citizens.(*) Perhaps Willcox, Himmelstein, and Woolhandler should have said, "If, over the last 7 years, physicians had not changed their drug-writing habits, they would probably still be writing 4,832,889 Persantine prescriptions for their elderly patients in 1994."

The Harvard study lays claim to the best of both worlds, taking its data from 1987 and its standards from 1994. One could easily forget that prescribing Persantine in 1987 was perfectly appropriate, based on standards of the day. Likewise, Vasodilan and Cyclospasmol were also legitimate drugs in 1987, since, at that time, both were still classified as possibly effective based on reviews by the National Academy of Sciences and the National Research Council.[12,14]

Next, notice that blood pressure pills are considered separately on Table 2 of this editorial. While the original Beers list consisted of 23 inappropriate drugs, the Harvard paper lays claim to only 20, omitting the three antihypertensives, Inderal (propranolol), Aldomet (methyldopa), and Serpasil (reserpine), which they determined were too controversial. However, after stating that they had excluded these three drugs, they included them anyway, in both table and text, along with their observation that the percentage of elderly being mismedicated was probably 32% rather than 23.5%.