Choosing Wisely: Medication and Treatments You Probably DON’T Need

Jennifer Yttri
August 2013

 

Medications and medical treatments can save lives and improve the quality of life, but there are almost always some risks. And, unfortunately, some patients won’t benefit even from the best treatments. When treatments are prescribed for patients who don’t need them or can’t benefit, it raises the cost of medical care for them, increases the cost of health insurance, and can harm individual patients as well. Bottom line: what is beneficial for one person may not be worth the risks for another.

The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

Consumer Reports magazine and the ABIM Foundation are working with medical specialty societies to create lists of “5 Things Physicians and Patients Should Question” as part of the Choosing Wisely campaign (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists are based on scientific evidence compiled by experts.

Here is the list of some of their recommendations about when medications or treatments are needed and when they are unnecessary.

Antibiotics for viral infections
Antibiotics kill bacteria but do not kill viruses, such as a cold or flu. Most respiratory infections, such as bronchitis and sinusitis, are caused by viruses and will clear up on their own in 1 or 2 weeks. Taking antibiotics when they won’t work can cause serious side effects for the patient, and also lead to antibiotic resistance of bacteria. Do not take antibiotics for infections unless symptoms last beyond two weeks or come back soon after getting better—these can be signs of a serious bacterial infection.

Antibiotics in elderly
Not all bacteria are bad for you. Elderly patients should not use antibiotics to get rid of bacteria detected in urine unless they are experiencing symptoms of a urinary tract infection. The antibiotics can cause more harm than the bacteria.

Antibody replacement therapy for recurrent infections
Unless a patient has a condition known as primary immunodeficiency disease, where they cannot make antibodies on their own, giving a patient replacement antibodies (also called immunoglobulins) is not recommended. Replacement therapy is expensive and a patient can have a serious allergic reaction or develop an infection. The only patients who should consider antibody replacement therapy are those who have frequent, unusual infections and very low antibody levels in their blood, certain immune disorders, or can’t make antibodies in response to vaccines.

Anti-nausea gels
A topical drug is easy to apply and therefore is an attractive therapy. But, topical gels should not be used to treat nausea because they are not readily absorbed through the skin and have not proven to be effective. Other therapies should be used instead.

Medications for patients with dementia
Antipsychotic medications (such as Abilify, Seroquel, Zyprexa, Geodone, Risperdal, and Haldol) should not be used to treat behavioral symptoms of dementia or Alzheimer’s disease. Antipsychotics do not treat the cause of these diseases and can cause very serious complications, including stroke or death.

Blood transfusion
Blood transfusion is not recommended for hospitalized patients who are in stable condition and do not have symptoms other than low hemoglobin levels. Blood transfusions should be given as sparingly as possible.

Bronchiolitis and respiratory infections in children
Respiratory tract infections are common in children. Corticosteroids and bronchodilators are not recommended for treating lower respiratory tract infections or bronchiolitis in children, because they are not proven effective and have risks that can be harmful.

Cancer therapy
The first round of cancer therapy works best at reducing or eliminating a tumor. Multiple treatments, including chemotherapy, will not always help get rid of cancer, especially more advanced cancers or tumors that return. After three different treatments, another round is unlikely to improve quality or length of life. It is better to stop therapy and not suffer through the side effects of treatment. (In fact, there is some evidence that patients live longer, with better quality of life, if they stop aggressive treatments earlier.)

Carotid stenosis or carotid artery disease
Carotid artery stenosis is a problem when plaque accumulates on the inside of arteries. It can be fixed by a surgical procedure to remove the plaque and damaged artery called carotid endarterectomy (CEA). CEA is not recommended for patients who may have plaque build-up but no symptoms. The CEA procedure is surgery and can have complications, including risk of stroke or death within 5 years of surgery, though in a small number of patients. Only patients with 70% blockage, a low risk for complications, and life expectancy at least 3-5 years should consider the surgery.

Chronic kidney disease
Chronic kidney disease (CKD) takes years to develop and symptoms rarely appear before the late stages (stages 3-5). Once symptoms develop, patients usually have other health problems caused by CKD. It is very important for patients with CKD and their families to talk with their doctors about which tests and treatments will improve or increase their life. Here are three examples:
• CKD can cause anemia, which means the number of red blood cells is low. Sometimes drugs that help make more red blood cells (called erythropoiesis-stimulating agents or ESAs) are prescribed before patients develop serious anemia. ESAs, however, are not recommended to prevent anemia because they are expensive and can put patients at risk for strokes, heart failure, and heart attacks. ESAs should only be used for patients who already have symptoms of anemia and very low levels of red blood cells.
• Patients in hospitals may have a catheter inserted into the vein of an arm to help nurses draw blood for tests and give IV medications. These catheters are not recommended for patients with late stage CKD as veins in the arms may be needed for hemodialysis. Catheters can damage these veins or cause scarring that makes it impossible to use the veins for hemodialysis.
• As CKD progresses, some patients may consider long term dialysis to perform the functions of kidneys. However, long term dialysis has not been proven to extend or improve life for patients with serious complications or short life expectancy. Dialysis also does not provide a benefit to patients with early stage kidney failure.

Cough and cold medications for children
Cough and cold medicines can have serious side effects and often contain more than one active ingredient. Research studies have concluded that these medications offer little benefit to children and can have risks of accidental overdose. Therefore they are not recommended for children under age 4.

Dialysis
The choice to start dialysis can be a difficult one. Long term dialysis is very unpleasant and may not improve survival or quality of life for older adults. Patients, families, and physicians should spend time discussing whether long term dialysis makes sense given a patient’s age, overall health, and life expectancy.

Ear infections
Oral antibiotics are not good at treating infections of the outer ear or infections from having a tube inserted to drain fluid from the inner ear. If antibiotics are needed for these ear infections, only topical antibiotics should be used.

Early labor induction or Cesarean delivery
Unless there is a clear medical reason, do not schedule delivery before 39 weeks and avoid scheduling delivery before 41 weeks. Babies born before 39 weeks are not fully developed and are at increased risk for learning disabilities, illness, and death. Mothers who deliver early are more likely to experience postpartum depression and may have complications from medicines needed to start labor.

Erectile dysfunction
Testosterone treatment is not effective as therapy for erectile dysfunction in men with normal testosterone levels. Erectile dysfunction is rarely caused by low testosterone levels. Testosterone therapy is costly and has high risks, including enlarged prostate, lower fertility, heart disease, and more aggressive prostate cancer.

Eye injections
Topical antibiotics, including antibiotic eye drops, are not recommended for use before or after eye injections. The risks of allergic reactions and antibiotic resistance are high.

Colony stimulating factors (CSFs) for febrile neutropenia
Febrile neutropenia, or severe fever with a low number of white blood cells, is sometimes a complication of chemotherapy. One in five patients will experience febrile neutropenia after chemotherapy but CSFs are frequently prescribed for all patients getting chemotherapy treatments. CSFs are only recommended for patients who are at high risk of infection, over 65, have a weak immune system, or have a greater than 20% risk of febrile neutropenia.

Feeding patients who have dementia
Using a feeding tube can cause distress to patients. If feeding tubes don’t work, this can cause ulcers or may require use of physical and pharmacological restraints that add to patients’ distress. Instead, patients with dementia should have someone help feed them, which makes sure they get nutrients and provides positive human interaction.

Gastroesophageal reflux (GERD) in infants
Antacids are not recommended to treat GERD in infants. It is not effective in reducing GERD symptoms and can produce adverse effects.

Heartburn, acid reflux disease, and gastroesophageal reflux (GERD)
There are many options for treating heartburn and GERD. Usually, treatment is based on getting rid of symptoms, not controlling or reducing disease. The most powerful drugs are proton pump inhibitors (PPIs), such as Nexium, Prevacid, or Prilosec. These drugs should only be used if heartburn happens more than twice a week or after a diagnosis of GERD. The lowest effective dose of a PPI should be used for the shortest amount of time. For less severe heartburn, changes in diet and lifestyle, antacids, or H2 blockers like Pepcid AC and Zantac can be effective without the risks associated with PPIs.

Headaches
Migraines are painful and can last a long time. Sometimes doctors prescribe strong pain medicines for migraines, such as an opioid (narcotic) or a barbiturate (sedative) called butalbital. These drugs usually do not help migraines and can make them worse. Instead, take medications specifically approved for migraines.

Implantable cardioverter-defibrillator (ICD)
ICDs are small, battery-powered defibrillators, similar to pacemakers, used in patients with irregular heartbeats. However, there are no guidelines for deactivating ICDs. Defibrillation can be unpleasant and there is no reason to continue their use if a patient is dying because it will not benefit the patient. It is recommended that ICDs be deactivated when patients no longer want this medical care.

Increasing blood circulation
Surgery to increase blood circulation to normally functioning heart, organs like liver and kidneys, or limbs will not prevent disease. Surgery to improve circulation is not recommended unless it will improve symptoms or is to remove a blockage.

Multiple sclerosis (MS)
Interferon-beta and glatiramer acetate (or Cop-1) are common MS medications. Both only work to reduce relapses and should not be given to patients with progressive, non-relapsing MS. The drugs do not stop the progression of disabilities related to MS and both are costly and have frequent side effects.

Nonsteroidal anti-inflammatory drugs (NSAIDS)
NSAIDS are drugs that relieve pain and inflammation. Common examples are ibuprofen (Advil and Motrin), naproxen (Aleve), and celecoxib (Celebrex). NSAIDS should not be used by patients with hypertension, heart failure, or chronic kidney disease. NSAIDS can react with drugs for hypertension, elevate blood pressure, and further decrease kidney function. Over-the-counter low dose acetaminophen (Tylenol) or short term use of narcotic painkillers may be safer choices.

Pain relief (palliative care)
Patients with severe illness who experience physical, psychological, social, or spiritual distress because of treatment should get palliative care. Palliative care is proven to reduce pain, control symptoms, and improve family satisfaction without high costs or risk of death.

Palliative care for bone metastasis
Cancers that spread to bones are often very painful. Local radiation is sometimes used to treat patients with one or a few bone metastases, but some doctors question if the increased risk of cancer warrants radiation as treatment for pain. The American Society for Radiation Oncology recommends using one dose of radiation to relieve pain from any bone metastasis. While another dose might be needed in the future, starting with one dose makes sense, since patients with bone cancer have a short life expectancy.

Pink eye
Pink eye can be caused by a virus or bacteria. Antibiotics should not be used to treat viral pink eye. A doctor should confirm that moderate to severe infections are caused by bacteria before prescribing antibiotics. Pink eye caused by a virus will clear up on its own.

Prostate specific antigen (PSA)
High PSA levels may be a sign of prostate cancer. However, having a low PSA level does not prevent prostate cancer nor does it mean there is no cancer. It was thought that antibiotics might lower PSA and protect men from prostate cancer. This has not been proven in clinical tests and is not recommended as an alternative preventive therapy.

Punctal plugs for dry eyes
Punctal plugs are put into tear ducts to keep liquid from draining away from the eye. Mild dry eyes should be treated with artificial tears before trying punctal plugs. Punctual plugs can cause inflammation of the eye and make symptoms worse, so they should only be used for more severe cases of dry eye that do not respond to simpler treatment.

Rheumatoid Arthritis (RA)
MRI is not recommended for diagnosing or monitoring RA. While an MRI may provide more information than other methods of assessment, it is not cost-effective in comparison to physical exams, lab tests, and x-rays, and therefore is not recommended as general practice. After a diagnosis, it is recommended that RA be treated with methotrexate or other conventional non-biologic antirheumatic drugs for at least 3 months before considering biologic drugs. Biologics may be better options for patients with aggressive disease and poor prognosis.

Sedatives in elderly
Sedatives like benzodiazepines should not be used to treat insomnia, agitation, or delirium, especially in the elderly as they are least likely to benefit from such treatment. Instead, sedatives may increase elderly patients’ high risk for accidents, falls and hip-fractures, which can result in hospitalization and possibly death. Sedatives should only be given to patients with alcohol withdrawal or anxiety disorders who do not respond to behavioral or psychological therapy.

Sinusitis
Sinusitis is diagnosed based on symptoms (e.g., nasal drainage, pressure, and nasal blockage) and is usually related to allergies or the common cold. Antibiotics should not be used to treat sinusitis because they usually don’t work. However, if symptoms are serious (high fever, rash, extreme pain) or they last for more than a week or keep coming back, generic amoxicillin, a very inexpensive antibiotic, is the best choice for treatment.

Stents in myocardial infarction
Stents are put into blocked arteries as a way to restore blood flow. However, stents are not recommended for patients who are undergoing angioplasty or percutaneous coronary intervention (PCI) for uncomplicated stable myocardial infarction (STEMI). Only one treatment is needed for uncomplicated cases, and adding stents may increase surgical complications and can even be fatal. Stents are also not recommended to improve blood circulation in arms and legs. Increasing blood flow in arteries that are not blocked will not prevent disease. However, stents and angioplasty in combination can be beneficial in patients who do not have stable blood flow.

Peripheral artery disease (PAD)
PAD develops when arteries in the legs and feet get blocked, restricting blood flow. Surgery and angioplasty are not recommended to treat PAD. Both procedures can only treat severe symptoms, like pain when walking, and do not prevent future problems. Safer and more effective ways to reduce symptoms from PAD are quitting smoking, walking daily, and controlling diabetes, blood pressure, and cholesterol.

Prophylactic treatment of stress ulcers
Medications to prevent stress ulcers (such as proton pump inhibitors or PPIs) are not recommended for hospitalized patients (non-ICU) unless they are at high risk for gastrointestinal tract problems. These costly medications can leave patients susceptible to bacterial infections, which are much more likely to develop in hospitals than stress ulcers.

Type-2 diabetes
Medications that treat diabetes by controlling blood glucose levels are only effective at lowering risk of death and artery clots after long-term use. The dose of medication prescribed for patients depends on how much is needed to maintain a specific level of glucose in the blood. For adult patients that are relatively healthy and have a long life expectancy, using medication for strong glycemic control may be worthwhile. However, as patients age (over 65) and develop other illnesses, patients are unlikely to benefit from strict control of blood sugar and are at high risk of complications from hypoglycemia.

Urinary catheters
Catheters are not recommended for treatment of incontinence, for monitoring bladder or kidney output for non-critically ill patients, or for convenience. They can do more harm than good when they are not medically necessary, because catheters cause urinary tract infections that can result in serious or even fatal illness, as well as increasing health care costs. Medical guidelines provide instructions on how to properly insert and maintain catheters for critically ill patients and recommendations on when to stop use or replace a catheter.