Time for a medication check-up?

Upgrading your pill organizer is a time-honored tradition associated with aging. Many older people take multiple medications, which typically include drugs for common problems like high blood pressure, high cholesterol, or diabetes, as well as those to treat heart conditions like atrial fibrillation.

But taking more than five daily medications — what doctors call polypharmacy — comes with risks, especially for seniors. An estimated one in five prescription medications taken by older people is inappropriate. Many of those are cardiovascular drugs that are potentially harmful, have no clear benefit, or aren't as good as other options. These should be stopped or switched, according to a review published June 14, 2024, in the European Heart Journal. For perspective and advice on this problem, we consulted Dr. Howard LeWine, an internist at Harvard-affiliated Brigham and Women's Hospital who's known for his dedication to deprescribing — that is, eliminating unnecessary medications.

The scope of the problem

"Some of the older patients I care for take as many as 15 pills every day, if you include multivitamins and supplements," says Dr. LeWine, who is also chief medical editor at Harvard Health Publishing. "Don't get me wrong; I love that we have all these medications that have made people's lives better," he adds. But as people age, they may develop different health problems and consult a range of specialists (cardiologists, endocrinologists, and orthopedists, for example), each of whom prescribes new medications. People may stay on these drugs for years, even when there's no good reason to continue. They may also take nonprescription products (see "Fish oil, vitamins, and other supplements"). Not only does polypharmacy raise the risk of worrisome side effects such as bleeding or low blood pressure, it's also a waste of money. Read on for specific tips about stopping or switching medications for heart disease and related conditions.

Treating high blood pressure

While more than 200 different drugs can lower blood pressure, the most commonly prescribed ones belong to a handful of drug classes. (For examples, see the overview from the American Heart Association). Over time, as new options reach pharmacy shelves and evidence about their effectiveness and safety accumulates, advice about the optimal classes and combinations shifts. One class that's falling out of favor is beta blockers. These are not the best option for treating high blood pressure and are no longer routinely recommended for long-term use after a heart attack. Also, taking one with a calcium-channel blocker can lead to severe dizziness.

Of course, beta blockers are safe and appropriate for certain people. But if you take one for high blood pressure, a drug from a different class (such as an angiotensin-receptor blocker or a thiazide diuretic) may make more sense, explains Dr. LeWine. In any case, don't stop taking a beta blocker abruptly, which can cause a rapid rise in your heart rate, possibly triggering chest pain.

Preventing heart attacks

For decades, doctors recommended low-dose aspirin to most middle-aged and older adults to help prevent a first heart attack. But the latest guidelines advise taking aspirin only if you've already had a heart attack or are at very high risk for one. If you don't have cardiovascular disease, the risk of bleeding from taking aspirin often outweighs the heart attack prevention benefit, Dr. LeWine says.

However, the advice about the other mainstay for preventing heart attacks — cholesterol-lowering statins — is a different story. If your doctor has prescribed a statin, keep taking it, even if you're in your 80s. Research published in the June 2024 issue of Annals of Internal Medicine suggests that statins lower cardiovascular disease in people ages 75 and older without any added risk of side effects. In fact, the benefits and safety were apparent even in people 85 and older. One caveat: If you take simvastatin (Zocor), consider switching to atorvastatin (Lipitor) or rosuvastatin (Crestor), as both are more effective options with fewer drug interactions.

The European Heart Journal review also recommends stopping niacin, which has no cardiovascular benefit and may have unpleasant side effects (for more detail, see "Is niacin safe for the heart?" in the June 2024 Heart Letter). People should also take care when using the popular pain relievers known as NSAIDs (see "Common oral NSAIDs"). The standard advice is to take the smallest dose for the shortest possible period of time, since long-term use of these drugs can increase the risk of heart attack and stroke.

Managing diabetes

The American Diabetes Association continues to recommend metformin as first-line drug treatment of type 2 diabetes. The review specifically recommends that people avoid drugs called DPP-4 inhibitors; examples include sitagliptin (Januvia) and saxagliptin. But these older drugs are rarely prescribed these days, Dr. LeWine says. Today, far better add-on medications for people with type 2 diabetes are either the GLP-1 receptor agonists or SGLT2 inhibitors. These drugs not only lower blood sugar levels but also reduce the risk of cardiovascular issues and premature death (see "Anti-obesity drug lowers heart-related problems" in the February 2024 Heart Letter).

Avoiding afib risks

People with atrial fibrillation (afib) typically take medications to reduce their risk of stroke — usually one of the anti-clotting drugs known as direct oral anticoagulants (DOACs), which include rivaroxaban (Xarelto) and apixaban (Eliquis). For the most part, those who still take warfarin, an older drug, should consider switching because DOACs are both safer and more effective. (The exception is people who have a mechanical heart valve, who should stay on warfarin.) Also, anyone who starts taking a DOAC but is already taking aspirin should definitely check to see if they should stop the aspirin, since both drugs increase the risk of bleeding. DOACs are more expensive, but generic versions are coming in the near future.

What you can do

First, make sure you understand the reason you take each of your prescribed drugs. If you aren't sure, ask the prescribing doctor for an explanation. Ideally, your primary care provider should review all your prescription medications (plus any over-the-counter drugs or supplements you take regularly) at least once a year. Check the list of medications in your online health portal to ensure the names and doses of the drugs recorded there match what you're currently taking.

Finally, if your blood pressure, cholesterol, or blood sugar values are close to ideal levels, losing weight, improving your diet (including drinking less alcohol), and getting more exercise may allow you to lower or eliminate certain medications.

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