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Friday, May 25, 2018
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Doctors disagree about blood pressure treatment

Patients get confused when doctors feud. That’s why controversial new guidelines for blood pressure treatment are causing consternation.

A committee of experts took five years to review all the available evidence and make recommendations for optimal blood pressure treatment. They are urging their medical colleagues to start drug treatment of older people (over 60) only when systolic blood pressure hits 150.

Many prominent cardiologists disagree. They want to stick with the old guidelines that focused on getting blood pressure down to 140 or lower.

You wouldn’t think 10 points would create such concern, but millions of older people will be affected. The previous guidelines were used as benchmarks: Did the doctor get patients’ blood pressure to 140/90 or lower? Doctors sometimes pushed blood pressures much lower than that in their zeal to meet the target.

In elderly people, lowering blood pressure so much may require three or even four medications. They may experience side effects from these drugs.

Blood pressure pills frequently cause dizziness, especially in older people. A study from Canada last year demonstrated that elderly people are at a significantly increased risk of falls and fractures during the first several months on a new blood pressure medication (Archives of Internal Medicine, Dec. 10/24, 2012). Since a hip fracture in an older person can lead to disability or death, these complications need to be taken seriously.

Nobody is suggesting, however, that really high blood pressure should be ignored or go untreated. Severe hypertension is a killer.

The problem with the previous guidelines, though, is inadequate evidence to support drug treatment at the lower target level of 140. The gold standard for establishing best practice rests on randomized, double-blind, placebo-controlled trials. But there just aren’t many studies showing that drug treatment of mild to moderate hypertension saves lives.

An analysis of all the available randomized controlled trials (RCTs) concluded last year: “Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9 percent of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.” (Cochrane Database of Systematic Reviews, Nov. 14, 2012)

There is no controversy about the value of controlling blood pressure with lifestyle changes. The DASH (Dietary Approaches to Stop Hypertension) diet has been proven effective. Exercise and weight loss also are helpful.


Q: My best friend has been having increasing difficulty this year with numbness and tingling in her feet and a loss of balance. Her doctor chalked it up to her age (79). When she fell in her bathroom and hit her head, she landed in the ICU, where a neurologist diagnosed her with vitamin B-12 deficiency.

She has been getting injections of vitamin B-12, and although she can see some improvement, she still has poor balance. She had been taking Prilosec (omeprazole) for heartburn and metformin for Type 2 diabetes. Apparently both drugs can trigger this deficiency. Why don’t doctors pay attention to the side effects of the drugs they prescribe?

Answer: Your friend is the victim of a double whammy. Vitamin B-12 deficiency has long been recognized as a serious complication of the diabetes drug metformin. A recent study showed that acid-suppressing drugs such as omeprazole, lansoprazole (Prevacid) and esomeprazole (Nexium) also can lead to vitamin B-12 deficiency (JAMA, Dec. 11, 2013).

Low levels of this vitamin may cause irreversible nerve damage. Symptoms include numbness, tingling or pain in toes, feet or fingers, trouble walking, memory problems and confusion, depression or burning tongue. Other symptoms can include loss of appetite, constipation and anemia. People taking any of these medications should have vitamin B-12 levels tested at least once a year.

Q: What can I do for a VERY itchy scalp? I have tried blue dandruff shampoo, but it didn’t help.

Answer: Some people report that soaking the scalp in milk of magnesia or amber Listerine before shampooing helps calm the itch.

Dandruff shampoos can help this condition, but they may work best if they are rotated every few weeks from one type to another. It is important to leave dandruff shampoo on the scalp for at least five minutes before rinsing.

Q: I have skin tags. How can I remove them without going to the doctor’s office?

Answer: Most dermatologists would recommend that you have skin tags removed surgically. These fleshy growths are benign and tend to show up in skin folds such as armpits, groin or around the neck.

Readers of this column have offered a number of remedies, with varying success. They include:

Liquid bandage: “I have used liquid bandage on skin tags with good success. Brush on twice a day. They will fall off within seven to 10 days.”

Clear nail polish: “I use colorless nail polish for skin tags. Apply once daily and they will disappear in a short while.”

Thread: “Years ago, I asked my doctor what to do about a skin tag. He told me to have someone tie a thread around it very tightly. It was a bit uncomfortable, but the skin tag soon disappeared.”

Others report success with applications of apple-cider vinegar or zinc-oxide ointment. If the skin tag does not respond promptly, have a doctor check to make sure it is not something more serious.

Joe Graedon is a pharmacologist. Teresa Graedon holds a doctorate in medical anthropology and is a nutrition expert. Write to them via their website: www.PeoplesPharmacy.com.

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