Are courses of drugs too long?

Drugs are here to stay but the way they should be used is changing. It started with antibiotics – too many are unnecessary. Now many drugs are prescribed for courses that are too long.

No ‘one-size-fits-all’ – neither for the choice of drug nor the duration of use.

More than two thirds of antibiotic courses for acute sinusitis in US adults were for 10 days or longer, whereas the guidance clearly recommends between five and seven days.

Antibiotic therapy for common bacterial infections can be shortened by at least three days for some conditions, for example acute urinary tract infections, strep throats, dental and middle ear infections.

Even some lifelong medications for conditions we thought worsen with age are now in question. For example, higher cholesterol and higher triglycerides seem to the extend life of women after the age of 65 and so lipid-lowering drugs should be stopped at that age. Similarly, evidence is now emerging that mildly high blood pressure has no effect in shortening life expectancy in the over 65-year-old age group. A large study found that no medication gave better outcomes for patients with moderate high blood pressure than a combination blood pressure pill.

Duration can therefore be influenced by not only the dose prescribed but also the inherent characteristics of the drug. It is clear that no ‘one-size-fits-all’ – neither for the choice of drug nor the duration of use.

The implications extend beyond clinical outcomes. Although the most commonly used antibiotics, lipid- lowering drugs and blood pressure medications are relatively cheap, they make up a large number of prescriptions and have budgetary implications. For example, should a three-day course of an antibiotic that is curative cost as much as a 5- or 10-day course of the same drug? Changing the length of a course of antibiotics for just two common infections would result in 1.1 million fewer days of antibiotics for respiratory tract indications and 100 000 fewer days for acute cystitis among females. The same demographic makes up nearly half the users of all antihypertensive medications in the US.

That kind of decrease could put a dent in even the sturdiest of pharma revenues and at the same time bolster the coffers of some of the community-based programs where cuts in funding are most severe.

2 thoughts on “Are courses of drugs too long?

  1. And when it comes to statins and strokes, there has been some recent evidence that cerebral blood vessels need higher levels of low density lipoproteins (so called “bad cholesterol”) – to retain flexibility in the vessel wall – than the levels we are aiming for to prevent cardiovascular disease. It’s as clear as mud, isn’t it?

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  2. The official guidance treating sore throat/pharyngitis/strep throat in Leicester for GPs is:

    Avoid antibiotics as 82% resolve in 7 days without antibiotics and pain only reduced by 16 hours.

    Calculate FeverPAIN Score

    Fever in last 24h, Purulence, Attend rapidly under 3 days, severely Inflamed tonsils, No cough or coryza.

    Score 0-1: 13-18% streptococci, use NO antibiotic strategy;
    Score 2-3: 34-40% streptococci, consider 3-day delay before antibiotic prescribed;
    Score = or > 4: 62-65% streptococci use immediate antibiotic if severe, if not 48hr delayed prescription.
    Phenoxymethylpenicillin (Penicillin V) 500mg QDS for 10 days.

    A few years ago, we prescribed for 5-7 days, now it is 10 days for highly likely strep infections as I think that there have been a few cases of rheumatic fever (something rarely seen in UK since the 1970s).

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