The Top 10

Alan Cook,DC, teaches the postgraduate seminar, "How to Win the Argument with an MD" at Life, Palmer West, and Parker Chiropractic Colleges.

"Whenever I have to choose between two evils, I always like to try the one I haven't tried before." -- Mae West

This is how many patients see their health care choices. Unfortunately, the two choices (evils) they see are drugs and surgery.

It is not enough to say, "No drugs, no surgery." We've got to be smarter than that. Physicians prescribe medication every day. Their selection of drugs is driven by patient requests, the standards of care, and/or the last visit by the drug sales representative.

But what are MDs prescribing? By understanding what the drug companies are selling, you'll better understand the prescribing habits of doctors and the demands of the public.

Are all of these prescriptions appropriate? Do these drugs have side effects? What are the risks and how likely are they? And if the public knew the truth about some of these drugs, would they continue to ask for them?

In 1994, expenditures for prescription medications exceeded $73 billion in the United States.¹ This eye-popping number helps explain why we see so many drug advertisements in the magazines in our waiting rooms, and the position of drug companies on the stock exchange.

No treating doctor has the time to learn about all of the hundreds of drugs available, but learning about the 10 most prescribed drugs is an excellent start. Among the top 10, many drug classes are represented.

The 1995 Top 10 Prescribed Drugs (new and refills) in the United States²

Drug	Manufacturer
Premarin tabs	Wyeth-Ayerst
Trimox	Apothecon
Snythroid	Knoll
Amoxil	SK Beecham
Zantac	Glaxo Well
Lanoxin	Glaxo Well
Procardia XL	Pfizer
Vasotec	Merck & Co.
Prozac	Dista
Proventil-Aerosol	Schering

Premarin has become almost synonymous with estrogen replacement therapy (ERT). ERT is recommended almost universally to women at the premenopause or postmenopausal time. The reasons given for the widespread use of ERT are relief of perimenopausal symptoms (hot flashes, night sweats, etc.), and protection against osteoporosis and cardiovascular disease.

The major objection to ERT is the association with an increase in the risk of breast cancer. This issue has been clouded by controversy, however the study with the greatest weight of evidence,³ is difficult to ignore. The risks of breast cancer for those using ERT for five or more years was 32-71 percent greater than for women who had never used hormone replacement therapy.

Trimox/Amoxil are in the antibiotic class of drugs representing 12-14 percent of all prescribed drugs.⁴ This widespread use continues despite numerous objections to the practice,⁵ the well demonstrated lack of efficacy,^6,7,8 and growing concerns about antibiotic-resistance.^9,10

A recent meta-analysis regarding otitis media in children⁷ found:

• Antibiotic prophylaxis of acute otitis media was seen in only one in nine children.
• For otitis media with effusion, a short course of antibiotics was an effective short-term clearance of the effusion in one of six children. The improvement was of relatively short duration.

In a 1995 letter,¹¹ two physicians asked, "What will it take to stop physicians from prescribing antibiotics in acute bronchitis?" The authors discussed the seven randomized double-blind studies showing "no major clinical role for antibiotics in uncomplicated acute bronchitis." Despite this evidence, physicians continue to prescribe antibiotics in an unjustifiable manner.

Synthroid is similar in chemical composition to L-thyroxine and is produced and secreted by the thyroid gland. Synthroid is used as thyroid hormone replacement therapy for anyone with decreased thyroid function. Thyroid levels need to be monitored via lab tests and dosage needs tend to decrease with age.

A recent study performed at the University of California at San Francisco found no advantage to the use of Snythroid when compared to lesser expensive generic drugs. Unfortunately, the manufacturer of Synthroid, Knoll, used some strong arm tactics to suppress the publication of this research.¹²

Zantac is a histamine H2 receptor antagonist, a class of drugs whose action is to depress the production of the stomach's production of hydrochloric acid. Zantac is used to treat heartburn, gastric ulcer, and duodenal ulcer. Prolonged use of this drug has been shown to induce liver damage.

Lanoxin is a digitalis preparation, originally extracted from the foxglove plant. It contains cardiac glycosides that act to increase the force and velocity of the heart muscle's contractions. Digitalis compounds are used to treat congestive heart failure an/or arrhythmias. Lanoxin is commonly prescribed with diuretics.

Vasotec is the most prescribed member of the angiotensin converting enzyme (ACE) inhibitors. Conversion of angiotensin I to angiotensin II is one of the regulatory mechanisms for blood pressure. It is prescribed for people with hypertension and/or congestive heart failure. Patients taking this drug must be monitored for adverse effects to the white blood cell count and for proteinuria. It can also induce birth defects, liver failure, and kidney dysfunction.

Procardia LX is an extended release calcium channel blocker used to treat angina, arrhythmias, and hypertension. Its mode of action is to lower vascular resistance both at coronary arteries and at peripheral sites. Initially released without the extended release form, Procardia (nifedipine) was implicated in increasing the death rate in patients treated with higher doses.¹³ Short acting nifedipine has therefore fallen out of favor.

Prozac is an antidepressant drug whose action is to inhibit the uptake of serotonin in the central nervous system. The two most common reasons for prescribing Prozac are depression and obsessive-compulsive disorder. Numerous adverse reactions to this drug have been reported, including: anxiety, nervousness, insomnia, drowsiness, fatigue, tremor, GI complaints, dizziness, and increased appetite.

Proventil Inhalation Aerosol is a bronchodilator and sympathomimetic drug. Its main action is to relax the smooth muscle that surrounds the respiratory tract thereby easing the passage of air.

These top 10 drugs represent over 240,000,000 prescriptions filled in the United States in 1995.² Learn about your competition. Learn about the wide health care market.

References

1. Johnson JA, Bootman JL. Drug-related morbidity and mortality. Arch Int Med, 1995;155:1949-56.
2. The top 200 drugs. American Druggist, Feb 1996:19-26.
3. Colditz GA, et al. The use of estrogens and pogestins and the risk of breast cancer in postmenopausal women. N Engl J Med, 1995;332:1589-93.
4. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA, 1995;273:214-9.
5. Mainous III AG, Hueston WJ, Clark Jr. Antibiotics and upper respiratory infection. J Fam Pract, 1996;42:357-61.
6. Van Buchem FL, Dunk JHM, Van't Hoff MA. Therapy of otitis media: myringotomy, antibiotics, or neither. Lancet, 1981;10/24/81:883-7.
7. Williams RL, et al. Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion. JAMA, 1993;270:1344-51.
8. Orr PH, et al. Randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature. J Fam Pract, 1993;36:507-12.
9. Breiman RF, et al. Emergence of drug-resistant pneumococcal infections in the United States. JAMA, 1994;271:1831-5.
10. Hofmann J, et al. The prevalence of drug-resistant streptococcus pneumoniae in Atlanta. N Engl J Med, 1995;333:481-6.
11. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics? (letter) Lancet, 1995;345:665-6.
12. Wolfe SM. So much for impartial scientific research. Health Letter; 12(6):12.
13. Furberg CD, Psaty BM, Meter JV. Nifedipine: Dose-related increase in mortality in patients with coronary heart disease. Circulation, 1995;92:1326-31.

Alan Cook, DC
Eureka, California