Dr Stephen Gascoigne Jigme Press Co. Cork Ireland 2003 Paperback, 280 pages, £16.99, Euros 25.00
(Reviewed by Dr Peter Helps, EJOM Vol. 4 No. 3)
In this book Dr Gascoigne aims to inform complementary medical practitioners (CMPs) about prescribed drugs. We live in a society where the use of pharmaceuticals, both prescribed and purchased over the counter is common practice. He states that 'almost 60% of general medical service patients in Ireland over the age of 65 take more than 2 medications'. In the US '12% of women over the age of 65 take at least 10 medications and 25% take at least 5 medications'. CMPs are therefore well advised to familiarise themselves with the major actions of commonly used drugs.
In the first part he addresses the important issue of how to respond when a patient asks, 'can I reduce or stop my medication?' Dr Gascoigne's answer to this question is to divide medications into 4 categories; the first being drugs taken occasionally or intermittently for symptom relief. Category 4 comprises drugs which are essential to life; for example insulin, cardiovascular and endocrine medication; queries concerning this group of drugs must always be referred to the general practitioner (GP) or specialist. However, in category 1 drug issues it may be appropriate for the CMP to give direct advice. For example, an acupuncturist may legitimately advise the patient to reduce or stop analgesics as and when symptoms improve.
Dr Gascoigne then goes on to look at drug treatments for common diseases, in chapters ranging from arthritis to infections and hypertension. Most of the information in these chapters concerns the side effects of drugs with almost no mention of their beneficial use; for example, under the heading 'Penicillins', surely it is worthy of note that they are lifesaving in meningococcal disease?
In the important chapter on hypertension his compilation of therapeutic agents starts with methyldopa – rarely used these days. Some of Dr Gascoigne's observations in this chapter might incite some of his orthodox colleagues. For example on page 105 he states that the diagnosis of hypertension is made if the reading is above 160/95. Conventional wisdom recommends 140/90 as a target for treatment. Furthermore there is good scientific evidence for treating systolic hypertension in the elderly, and therefore his statement that 160mmhg 'would seem to be a low figure for someone over 65 or 70' is probably incorrect for most elderly people. Having said that, in my own practice I would probably accept a systolic pressure of 165 in an otherwise well 95 year old.
In his chapter on arthritis, a condition frequently treated by CMPs, I would like to have seen more information on the interesting mechanisms of action of non-steroidal anti-inflammatory drugs, widely used and available without prescription. Furthermore, this group of drugs is responsible for much iatrogenic disease, large numbers of elderly people suffering gastrointestinal bleeding with a high mortality rate. I would have liked to have seen this important issue highlighted.
The chapter on psychoactive drugs starts with a discussion on antidepressants, so widely used in this society. Dr Gascoigne states that in the UK 1:12 women and 1:25 men regularly take antidepressants. The cost of antidepressants prescribed in the US was $12 billion in 2001. He starts the chapter with monoamine oxidase inhibitors - almost never prescribed by GPs these days. His section on selective serotonin re-uptake inhibitors, which includes Prozac and Seroxat, should have highlighted the importance of slow withdrawal from these drugs, since stopping abruptly often causes giddiness and unsteadiness. I felt some explanation of the value of medication in the treatment of severe mental disorders should have been mentioned in the preamble to the chapter. Despite a high incidence of side effects, especially with older tricyclics, medication may be very helpful to some people at some time in their lives. When a person is emerging from a psychoemotional disorder CMPs have much to offer, given that they often have time to listen, and therapies can target troublesome symptoms like anxiety and panic attacks. In this situation it is reasonable to gradually reduce medication under medical supervision. It is here that communication between GP and CMP would yield much benefit to the patient.
Much of the book concerns itself with the side effects of drugs, an issue of great importance to all health care professionals. However, I would prefer to see common side effects highlighted. For example, in the case of ACE inhibitors in the treatment of hypertension, dry cough is common and intolerable in some patients, but its significance is lost amid his list of rare side effects.
Dr Gascoigne has his feet firmly in the CAM camp, and I think this gives the book a somewhat unbalanced feel. It is worth remembering that many people take medication with no or few unwanted effects. An example is modern antihypertensives which are much better than those in use 15 or more years ago, and contribute significantly to reducing the incidence of cardiovascular disorders.
We live in a society where prescribed drug use is common; it behoves CMPs to be well informed about the drugs their patients are consuming. This book will aid them in this important task, and makes a valuable contribution to the development of integrated medicine.
Dr Peter Helps Dr Helps worked in Accident and Emergency for 10 years prior to entering NHS general practice in 1985. He is currently a part-time NHS general practitioner and TCM acupuncturist in Brighton and Hove in the UK.