You hear the pitch in drug ads all the time: "Ask your doctor if this medication is right for you." Trouble is, in many cases the only way your doctor can answer the question is by having you try the drug. And, as the latest research reveals, what's "right" for the smiling folks in a TV commercial may be just plain wrong for you.
One reason: Each of us responds uniquely to any given medication. "Your liver and kidney function, overall health, treatment for other conditions, and genetics all play a role in how a drug affects you," says Martha Gerrity, MD, PhD, clinical evidence specialist at the Center for Evidence-Based Policy at Oregon Health & Sciences University.
Another reason: The chances of your having a good response are simply not in your favor. "To market a medication, all you have to do is prove that it's better, on average, than a sugar pill," says Mark Gibson, deputy director of the OHSU center. A drug that works 20 percent of the time, for instance, may be considered effective — even though it does nothing for 80 percent of patients.
Those odds could improve soon, thanks to a national push to comb through studies and scientific reviews to determine who gets better most often on which drugs. Called comparative effectiveness research, the initiative aims to produce a reliable set of guidelines that will enable you and your doctor to choose treatments based on solid evidence, not guesswork. The Obama administration has made comparative effectiveness research a priority, funneling over $1 billion — "a huge increase," says Gibson — into the program as part of the government's stimulus package.
Already, 28 research centers funded by the government's Agency for Health care Research and Quality (AHRQ) have produced a wealth of findings on treatments for many common, chronic conditions. If you suffer from one of them, first start with lifestyle changes such as exercise and a modified diet. Then, when you're ready to try drug treatment, talk to your doctor about the steps outlined here — all supported by powerful new research.
High blood pressure
If you're overweight, you can lower your blood pressure by losing just 5 pounds. And healthy strategies for dropping those pounds — exercising; consuming less saturated fat; and eating more fruits, vegetables, and whole grains — can each help tame hypertension. But you may still need medical treatment, depending in part on how high your blood pressure is.
First, try... a diuretic, which takes pressure off blood vessels by making the body eliminate water and sodium. "Many people with hypertension who take a diuretic alone are able to bring blood pressure down to a target of 130/90 or, ideally, 120/80, with relatively few side effects," says Gerrity.
If that doesn't work... take a two-pronged approach by adding a beta-blocker, ACE inhibitor, or angiotensin II receptor blocker (ARB), all of which work in a manner different from that of your diuretic.
Tailor your treatment
If you have diabetes or kidney problems: Make your second drug an ACE inhibitor, which protects the kidneys.
If you're African American: Consider starting with a combination treatment that includes a diuretic: African Americans generally don't respond as well to treatment with just one drug.
If blood pressure is really high: Start right away with combo treatment to quickly bring down systolic blood pressure if it's 160 or higher, or diastolic blood pressure if it's 100 or higher.
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If you have ischemic heart disease (which can cause your pulse to be irregular or rapid): Instead of a diuretic, start with a beta-blocker, which can help lower your heart rate.
If you're pregnant: Avoid ACE inhibitors and ARBs; they can cause birth defects. Better choices: beta-blockers and vasodilators that relax blood vessels.
Go natural: Omega-3 fatty acids lower blood pressure, but only in high doses (above 3 g a day) that may increase your risk of bleeding, so take them only under a doctor's supervision. Coenzyme Q10 may also cause small drops in blood pressure and may lower blood sugar in some people, so be cautious if you're taking diabetes medication.
Type 2 diabetes
Diet, exercise, and weight control are among the most potent tools for bringing down high blood sugar. A 10-pound weight loss — even in someone who is obese — can help patients with diabetes as much as adding another medication, says Gerrity. A variety of drugs also effectively control blood sugar.
First, try... Metformin (Glucophage), which decreases the amounts of glucose absorbed from food and made by the liver. Metformin is older and cheaper than many other drugs, but it matches or outperforms the newer thiazolidinediones (Actos, Avandia), according to a new review.
If that doesn't work... combine metformin with a second drug, such as a sulfonylurea, which increases the body's insulin production. "Because metformin and sulfonylureas work in different ways, the drugs lower blood sugar together better than either drug would by itself," says Gerrity.
Tailor your treatment
If you're overweight: Stick to metformin; it won't make you gain weight.
If you have high cholesterol: Avoid Avandia and Actos, which can raise "bad" LDL cholesterol and worsen congestive heart failure, according to AHRQ reports. Opt for metformin, which can lower LDL.
If you have a sensitive stomach: Take a smaller dose of metformin, which is more likely than other diabetes pills to cause diarrhea and stomach cramps. If the lower dose proves less effective, combine metformin with a different drug to keep blood sugar under control.
Go natural: "Eat high-fiber, unprocessed foods, especially legumes," advises Kevin Barrows, MD, interim director of clinical programs at the Osher Center for Integrative Medicine at the University of California, San Francisco. Some reports suggest you can also lower blood sugar by taking the botanicals Gymnema sylvestre and bitter melon (but don't combine them with prescription meds).
Exercise can brighten your blues by reducing stress, releasing muscle tension, building self-esteem, helping you sleep, and boosting levels of feel-good brain chemicals. But you may need treatment to help get you going if you're feeling listless. Six out of 10 people feel better on the first antidepressant they try; the rest need to try other drugs, according to the AHRQ. Ask your doctor about the cytochrome P450 genotyping test, a genetic analysis that can help you predict which drugs will work best for you and whether you're more likely to experience side effects.
First, try... a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil), or sertraline (Zoloft). Most people feel these drugs help, and research finds that they have fewer side effects than other antidepressants.
If that doesn't work... Tricyclic antidepressants work as well as SSRIs do, although side effects are usually more numerous and severe.
Tailor your treatment
If you're overweight: Avoid paroxetine and mirtazapine (Remeron), which are more likely to cause weight gain than drugs like fluoxetine and sertraline, according to a government report. Consider bupropion (Wellbutrin), which tends to shave off 2 or 3 pounds.
If you have sexual problems: Bupropion is less likely to cause loss of desire or trouble reaching orgasm than fluoxetine, sertraline, and especially paroxetine.
If you also take drugs for diabetes or high blood pressure: Watch glucose and BP levels more closely. Both sulfonylureas and beta-blockers use the same chemical pathways in the liver as antidepressants, so starting an SSRI may increase or decrease the potency of these medications, says Gerrity.
Go natural: Supplements of SAM-e, a naturally occurring building block of brain chemicals (such as serotonin) that help stabilize mood, were found to significantly boost patients' spirits in an AHRQ review of 28 studies.
Staying active should be a lifelong strategy: Walking and other moderate exercise can reduce pain, keep you flexible, and strengthen muscles supporting your joints. However, many joint pain sufferers find they need more help.
First, try... Methotrexate for rheumatoid arthritis. Called a DMARD (disease-modifying antirheumatic drug), it suppresses the immune system attacks that characterize the disease, tamping down the inflammation that causes joint damage and pain. It also comes in a pill that can be as effective as similar drugs delivered in shots or IV treatments, according to a new government guide. If your pain is caused by osteoarthritis, start with acetaminophen (Tylenol), the OTC painkiller least likely to cause side effects.
If that doesn't work... A combo of methotrexate and a DMARD injection usually works better than methotrexate pills alone for people with more aggressive and drug-resistant rheumatoid arthritis. Don't double up with another oral DMARD — the research shows that pills generally aren't more effective together than they are alone. For osteoarthritis, try naproxen (Aleve, Naprosyn), an NSAID that doesn't increase your chances of a heart attack like celecoxib (Celebrex) and diclofenac (Voltaren) do.
Tailor your treatment
If you're at risk of heart disease: Avoid ibuprofen (Advil, Motrin): It poses cardiovascular risks for more people than other anti-inflammatories do, reports the American College of Rheumatology.
If you're over age 45: Try to use anti-inflammatories sparingly. At least 3 times as many people in this age group experience serious stomach bleeding, compared with younger adults taking these drugs.
If you're premenopausal: Use two forms of birth control (such as the Pill plus a condom) while taking methotrexate, which can cause serious birth defects.
Go natural: Try fish oil supplements containing omega-3 fatty acids for rheumatoid arthritis: "Fish oil appears to be a potent anti-inflammatory," says Barrows. He recommends 3 g of omega-3s daily, possibly increasing to 6 g if needed, so check the appropriate amount with your doctor. For osteoarthritis, glucosamine hydrochloride with chondroitin sulfate may ease moderate to severe pain with few possible side effects, says the AHRQ. "Although some recent research concluded chondroitin doesn't help, far more studies have shown that it does," says Barrows.
Nondrug solutions can work as well as or better than medication for insomnia, although they may take 1 to 3 weeks to become effective. One recent review of 37 studies found that mental techniques such as trying to stay awake instead of trying to fall asleep — a reverse psychology technique known as paradoxical intention — consistently helped insomniacs nod off. But resistant sleep problems often need to be addressed with drugs.
First, try... Zolpidem (Ambien): "It's effective in 75 to 80 percent of people who try it and is generally safe," says James Walsh, PhD, executive director and senior scientist at the Sleep Medicine and Research Center at St. Luke's Hospital in Chesterfield, MO.
If that doesn't work... Try a longer-acting sleep medication, such as eszopicione (Lunesta) or Ambien CR, both of which are active in the body for approximately 8 hours.
Tailor your treatment
If you have trouble falling asleep: You'll nod off faster after taking Sonata than you will if you take Ambien, according to a review by the Oregon Evidence-Based Practice Center.
If you wake during the night: Ambien, Lunesta, and other sleep medications tend to provide longer sleep duration than Sonata and keep people asleep once slumber overtakes them.
Go natural: "Cognitive behavioral therapy can work as well as drugs, and its effects last up to 6 months after you stop treatment," says Walsh. In CBT, you redirect your mind away from anxiety-producing thoughts and start spending less time in bed, not more. That makes you more tired the next time you hit the sack, so sleep comes easier. "Once you're sleeping better, you can start sleeping longer," says Walsh. Go to nacbt.org to search for a therapist.
Keeping a headache diary is one of the best ways to identify your triggers and possibly prevent future attacks. It also helps your doctor find a prevention and treatment plan that works for you. Record possible food triggers, emotional stress, alcohol consumption, medication, hormonal changes, and sleep patterns. Still, the throbbing onslaught of headache pain can be difficult to predict, so a variety of drugs have been developed specifically to treat migraines — and some designed for other conditions may help as well.
First, try... an OTC or prescription NSAID such as ibuprofen, or a combo drug such as Excedrin Migraine, which contains acetaminophen, aspirin, and caffeine. These drugs will often relieve mild to moderate migraine pain but may not help a severe attack, according to guidelines from the American Academy of Neurology. "Take an NSAID as soon as you feel a migraine coming on," says Gerrity. "It's more effective at the beginning of the headache."
If that doesn't work... Try a triptan, such as sumatriptan (Imitrex) or rizatriptan (Maxalt), which can relieve pain, nausea, and sensitivity to light but has relatively few side effects. Research shows that sumatriptan works especially well when taken with naproxen (an NSAID). And a review from OHSU's Evidence-Based Practice Center found rizatriptan especially effective at providing 2-hour relief, compared with sumatriptan and naratriptan.
Tailor your treatment
If you're treating high blood pressure: Consider using beta-blockers, which can make migraines milder and less frequent. If that doesn't help, try a calcium channel blocker, such as verapamil (Calan, Isoptin), another type of high blood pressure medication that may also relieve migraines.
If migraines strike more than twice a month: Try a medication shown to prevent migraines, such as a tricyclic antidepressant or an antiseizure drug like topiramate (Topamax).
Go natural: There's good evidence that butterbur is an effective supplement in treating migraine pain. And magnesium supplements may make migraines less frequent by correcting deficiencies that seem to be more common in migraine sufferers. "Feverfew and riboflavin may also help," says Barrows. Combination products like MigreLief put magnesium, feverfew, and riboflavin in a single pill.
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