ARE YOU SENSITIVE TO MEDICATIONS?
Dr. Cohen's Primary Principle: The best dose of any medication is the least amount that works effectively.
Many people are concerned about medication side effects. Their concern is warranted since the risk of side effects with many medications is high. In fact, medication side effects are the #4 leading cause of death in America (150,000 deaths annually). And more than a million people are hospitalized annually due to side effects of medications.
Dr. Cohen estimates that approximately 15 to 25 percent of people are medication-sensitive, a term he coined in 1993. These individuals are sensitive to many of the medications they receive. As one pharmacist said: "You run into patients all of the time who don't tolerate standard drug doses."
Dr. Cohen has conducted research on this issue for more than 40 years. He described the problem in his highly praised look, Over Dose: The Case Against The Drug Companies (Putnam 2001). People are surprised to learn that drug companies do not strive to identify the lowest, safest doses of medications. Instead they seek higher dosages with which they can cover a broad population of billions of people, a dosage that is strong enough to impress the FDA and win quick approval.
The Problem with the Prozac Paradigm
The classic example is Prozac, introduced in 1988, which helped many of Dr. Cohen's patients more than any previous antidepressant. "Prozac was truly a breakthrough drug for half of my depressed patients." Unfortunately, for the other half, it provoked serious, sometimes alarming side effects. The directions were to start all patients on 20 mg, but Dr. Cohen knew this would be a problem. Dr. Cohen's research identified a study by Prozac's manufacturer showing that 54% of patients only needed 5 mg. When Prozac was marketed, there was no mention of this finding, and the only pill was 20 mg. No wonder 20 mg was too strong for half of Dr. Cohen's patients.
If You Are Medication Sensitive, You Are Not Alone
The most highly sensitive individuals are often also sensitive to many types of chemicals. For one woman, coffee causes a painful flaring of the cystic disease of her breasts. One doctor gets depressed whenever he takes one Motrin tablet. A woman is sedated by Claritin (which is supposedly nonsedating, but actually sedates 1 in 12 people). Many medication sensitive individuals cannot handle alcohol.
"If you are medication sensitive, you may think you are the only one intolerant to medications. Yet you have plenty of company."
The majority of medication sensitive individuals are women, but some men are sensitive too. Medication intolerances can also run in families. Older people are often sensitive to medications, and the older they get, the more sensitive they become. A highly experienced pharmacist noted, "As people age, nearly all of them become medication sensitive." And older people also are prescribed many types of drugs, so the risk of adverse drug interactions grows.
"My mother died not of her disease, but from her medications," one woman told me. "Even as the doctors prescribed more and more drugs to her, none made an effort to minimize the doses she received to prevent a serious drug interaction."
Greater Risks for Women
The majority of people who contact Dr. Cohen about medication problems, like the woman who wrote the note above, are women. Dr. Cohen says,
"My experience is that the great majority of medication sensitive individuals are women, and therefore they are most vulnerable to unnecessarily strong drugs. Age is also a factor because women, on average, live longer than men. They are also smaller, which adds an additional degree of risk."
Recent revelations about higher plasma levels of Ambien in women vs. men led the FDA to require a lower dose for women, 5 mg, instead of the previously recommended 10 mg. Dr. Cohen believes that these gender differences occur with most medications. Unfortunately, the medical-pharmaceutical complex is about producing and marketing drugs, not spending the time and cost to ensure greater precision and safety in medication treatment. For example, many doctors still prescribe high doses of Premarin (a horse hormone) rather than modest doses of natural estrogen for women with menopausal symptoms.
A Safer Approach
For more than two decades, Dr. Cohen has been writing books and articles about how to avoid these problems. He has lectured at the U.S. Food and Drug Administration and major medical conferences, trying to spread the word on starting patients with lower, safer dosages.
Dr. Cohen has a different perspective on side effects than most other doctors. Dr. Cohen believes that doctors are not adequately trained to treat people as individuals. Too often, doctors prescribe the same strong medication doses to a 105 pound woman, a 90 year old, 90 pound, great grandmother taking 15 other drugs, a skinny 12 year old, and Shaquille O'Neal. You don't have to be an expert to realize that such methods do not make sense.
Unfortunately, doctors employ these same one size fits all methods with statin cholesterol lowering drugs, drugs for high blood pressure, anti inflammatory drugs (NSAIDs), hormones, gastrointestinal medications, antidepressants, sleep remedies, migraine drugs, and more.
In contrast, Dr. Cohen advises a flexible, individualized method that, except in urgent medical situations, begins with low doses of drugs. He selects therapies and doses based on each person's individual characteristics: age, gender, size, state of health, use of other medications, history of previous problems with medications, family medication history, and other factors. When handled with an emphasis on safety, medication treatment (or natural therapies) can make a big difference in your quality of life.
Of course, side effects can occur even in people with normal tolerances to medications. This also can happen when a medication dose is increased. For example, you may be taking 40 mg of Lipitor (for elevated cholesterol), and your doctor may want to increase the dosage to 80 mg. This is a big increase, a 100 percent jump. Many people have difficulty when drug doses are increased in 100 percent gradations. Yet, this is common practice in mainstream medicine. Why not increase more gradually, for example from 40 mg of Lipitor to 60 mg? Indeed, this more gradual increase is often enough for people to reach their cholesterol-lowering goals.
Doctors and Side Effects
One medication sensitive woman told Dr. Cohen, "I react to everything. I don't know what will happen when I really need treatment." Her concern is warranted. When patients develop side effects, they are often switched from drug to drug rather than to simply reduce the doses, thereby reducing the side effect risks. The result is a series of unpleasant reactions. A letter published in the Peoples' Pharmacy column illustrates the problem.
"We visited my mother over the holidays, and she just isn't her old self. I'm convinced the problem is her medicine. She has been on Prozac, Paxil, Effexor, Zoloft, and Celexa. She has suffered from anxiety and restlessness, insomnia, dry mouth, and nausea. Her doctor is ready to give up. She is currently taking Remeron, but she is tired and dizzy all of the time. She also has gained weight."
All of these medications can cause a host of side effects when prescribed at excessive doses. Treatment must be individualized. The dose must be matched to the patient's tolerance. Clearly, this woman's doctor did not know how to do so. This is why, when Dr. Cohen prescribes any of the above medications, he starts people on doses that are 1/2 or even 1/4 the standard amounts.
Dr. Cohen's Guiding Principle: Why Use More Than Needed?
The highest ethic of the medical profession is: Do No Harm. For Dr. Cohen, preventing side effects is as important as selecting an effective drug. If a medication dosage is beyond a person's tolerance, treatment cannot continue. As one of Dr. Cohen's patients said, "I don't know why doctors start with strong doses first. They should start with low doses and, if needed, increase the dosage gradually, carefully."
Many patients obtain benefit with low doses and never need to increase. Except in an emergency, the low-dose approach works well for most people. Most people understand this intuitively, but many doctors unfortunately don't.
- Newsweek. One-Size-Fits-All Medications Do Not Fit All: Doctors and Patients Need to look beyond cookbook guidelines from the drug industry. Dec. 6, 1999, page 92.
- Life Extension Magazine. Medication Side Effects: Why They Occur and How You Can Prevent Them. March 2003;9(3):46-68.
- Bottom Line Health and Bottom Line Personal Newsletters. Multiple articles and interviews on preventing medication side effects. 2002 through present.
- Special from Bottom Line's Daily Health News. Four More Drugs with Serious Health Risks. February 28, 2005.
- Life Extension Magazine. Tylenol: More Risky Than You Realize.
- JAMWA (The Journal of the American Medical Women's Association). Do Standard Doses of Frequently Prescribed Drugs Cause Preventable Adverse Effects in Women? 2002;57:105-110. The first in-depth article to examine why women sustain more side effects than men.
- Medscape. Preventing Adverse Drug Reactions Before They Occur. Expert Pharmacology Column. Dec. 1999: www.Medscape.com.
- Postgraduate Medicine. Ways To Minimize Adverse Drug Reactions: Individualized Doses and Common Sense Are Key. Sept. 1999;106:163-72.
View all of Dr. Cohen's medical articles, consumer publications, and presentations.
NOTE TO READERS: The purpose of this E-Letter is solely informational and educational. The information herein should not be considered to be a substitute for the direct medical advice of your doctor, nor is it meant to encourage the diagnosis or treatment of any illness, disease, or other medical problem by laypersons. If you are under a physician's care for any condition, he or she can advise you whether the information in this E-Letter is suitable for you. Readers should not make any changes in drugs, doses, or any other aspects of their medical treatment unless specifically directed to do so by their own doctors.
If you have questions about your medications or medical care, Dr. Cohen is available for consultation at his office or by telephone.
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