Dec. 4, 2008

Dear Dr. Spence,
Is there any value in treating high blood pressure in an 84 year old? My father is on three medications. He is generally healthy, but the cost is progressively becoming an issue.
Signed,
Heir Apparent

Dear Heir,
Great question. I think there is great value in maintaining blood pressure in an elderly patient and this has been supported in the literature. The HYVET study (Hypertension in the Very elderly Trial) evaluated 3845 patients with an average blood age of 83.6 who had a systolic blood pressure greater than 160 mm Hg. These patients were placed on either one or two drugs depending on response. At two years, anti-hypertensive drug therapy reduced fatal stroke by 39%, death from cardiovascular disease by 23%, death from heart failure by 64% and death from all causes by 21%. Not only that, these patients were generally free of underlying heart disease. One may have expected even more impressive numbers had they used a more representative sampling of the geriatric population as nearly 70% of patients over 80 years of age have heart disease or diabetes.
Blood pressure control is crucial regardless of age. It is recommended to treat at least 140/90 or less for the majority of patients. Cost is certainly an issue, however. Generic combinations can generally be effective in achieving optimal control.

Dear Dr. Spence,
What’s all the fuss about liver damage with the use of medications like lipitor or zocor? I saw the TV ads and now I’m paranoid that I’m destroying my liver completely!
Signed,
Hadda Sclerosis

Dear Hadda
Undoubtedly, the perceived risk associated with the use of statins medications (those for cholesterol lowering) are grossly overstated. The FDA recommends checking liver functions, a marker of liver damage, at the start of therapy, at 6-12 weeks and periodically thereafter. An analysis of 35 studies involving 74,102 patients reported the risk of liver function test elevations to be 4/1000. Other studies suggest that severe elevations may only occur in 0.1% of patients treated. The FDA reports only 0.69 cases of true liver failure or hepatitis for each one million prescriptions written.
There does seem to be widespread concern about the damaging effects of these drugs. I have witnessed it countless of times in my own office. It is crucial to recognize the positive effects that the statin class may provide. Only 27 patients would need to be treated with a statin to prevent one cardiovascular death whereas the number needed to harm one patient is approximately 3400. Usually, even with an increase in liver function tests, discontinuation of the offending agent quickly reverses these numbers back to normal.
Given the overwhelming greater likelihood of dying from a massive coronary versus suffering statin induced liver damage, I say use the statin. Further, though it is suggested that periodic testing be done to evaluate for liver damage (every six months is standard), there is really no evidence proving it is either helpful or necessary. I still check as recommended mostly because I’m not fond of lawyers (no offense).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.