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ESTES PARK, COLO. – Topping Dr. Jeffrey I. Wallace’s pantheon of peeves in prescribing for the elderly are:
• Megestrol acetate (Megace): These are widely prescribed in older patients who aren’t eating well and are experiencing failure to thrive. But the randomized trials with 6- to 12-month followup clearly show that any modest benefit achieved in terms of weight gain takes 2-3 months of therapy. And megestrol acetate is a progestational agent associated with increased risk of thrombotic events and a possible increase in mortality.
"The data on Megace really look terrible. I much prefer using mirtazapine to increase appetite in a patient with even a hint of depression. I’d probably use medical marijuana in the form of Marinol [dronabinol] before I’d use Megace," declared Dr. Wallace at an update in internal medicine sponsored by the University of Colorado, Denver, where he is a professor of medicine.
• Oral iron more than once daily: "I see patients in the nursing homes all the time who’ve been discharged from the hospital by the surgeons on T.I.D. (three times a day) iron," according to the geriatrician.
Absorption of iron is an active process occurring in the duodenum and jejunum. By taking once-daily iron, a patient gets roughly 75% of all the iron that can possibly be absorbed in a day. Moving up to B.I.D. iron, that figure rises to 90%, and T.I.D. dosing bumps up another 5%.
"So each time, I get a little more iron absorbed. The problem is I get a lot more GI side effects. Most of the geriatric patients I see after they get out of the hospital aren’t feeling good already – and now I’m going to make them constipated and give them some dyspepsia and decreased appetite? It’s just not worth it; you don’t get much more bang for the buck. I’m pretty much a stickler to always take the iron down to once a day," he said.
A tip: Oral iron requires an acid environment to be absorbed well. A patient who has had a GI bleed or is at increased risk because of chronic NSAID therapy is likely to be on a proton pump inhibitor, which will interfere with iron absorption. "Have the patient take the iron with some orange juice or vitamin C to help absorption. The data isn’t all that good that it makes much difference, but it’s worth a try," according to the geriatrician.
• Muscle relaxants: These medications are sedating; cause anticholinergic side effects and are linked to an increased risk of falls; and are of questionable efficacy.
"It used to be that if you were 65 or 70 [years old] and came to the ED with back pain, everyone walked out of there with Flexeril [cyclobenzaprine] or some variant thereof. Our ED at the university pretty much doesn’t hand out muscle relaxants anymore. They’re not really pain pills; the data are terrible in terms of helping pain. For run-of-the-mill back pain, I’d rather give an older patient an opiate than a muscle relaxant. So unless you have a definitive muscle spasm, treat the pain with pain pills," he urged at the conference.
He reported having no financial conflicts.