Medicines Information in the wrong hands is a detriment to Patient Safety: The Pharmacists’ Mandate

The other day, Twitter blew up with the post (see image below) giving instructions on the ancillaries to take alongside Anabolic Steroids. The ancillaries happened to be medicines that are taken for various disease conditions. The alarming reality of circulating such misinformation is that this is an unnecessary ‘Prescribing Cascade’ orchestrated with much unprofessionalism that has the propensity to cause much harm and even result in loss of lives.

A Prescribing Cascade is misinterpreting an adverse drug reaction (ADR) to one drug as a new medical condition, leading to the subsequent inappropriate prescription of a second drug. In the above scenario, the ancillaries are supposedly meant to be used off-label to combat the potential side effects of anabolic steroids. According to the U.S. Food Drug and Administration (FDA), off-label drug use involves prescribing medication for an indication using a dosage or dosage form that has not been approved. A qualified professional can only do this in cases where the benefits outweigh the risks and no FDA-approved drug is available for the specific condition.

Pursuing a perfect body leads most people to abuse drugs and use anabolic steroids. Anabolic steroids are prescription-only medicines, sometimes taken without medical advice, to increase muscle mass and improve athletic performance. They are synthetic substances that mimic the action of testosterone, the primary androgenic hormone that promotes the growth of skeletal muscle and the development of male sexual characteristics.

As with any drug, there are some side effects that one may experience with such. These include:

Physical side effects of anabolic steroids in men:

• Reduced sperm count
• Infertility
• Shrunken testicles
• Erectile dysfunction
• Hair loss
• Breast development (Gynaecomastia)
• Increased risk of prostate cancer
• Severe acne

 Physical side effects of anabolic steroids in women:

• Facial hair growth and body hair
• Loss of breasts
• Swelling of the clitoris
• A deepened voice
• An increased sex drive
• Problems with the menstrual cycle
• Hair loss
• Severe acne

Additionally, both men and women who take anabolic steroids can develop any of the following medical conditions:

• Heart attack or stroke
• Liver/kidney failure
• Hypertension
• Blood clots
• Fluid retention
• Elevated cholesterol

To place the medicines in the image captured in context:

1. Metformin: This is an Oral Hypoglycemic Agent. The main indication is Type 2 Diabetes and Polycystic Ovarian Syndrome. It works by increasing insulin sensitivity and inhibiting glucose synthesis by the liver. Decreasing glucose production by the liver and glucose absorption by the intestine reduces insulin secretion by the pancreas. This ultimately increases the body’s dependence on fat stores for energy dependence.
2. Telmisartan(Telmicos): An Angiotensin Receptor blocker used to manage Cardiovascular Disease e.g Hypertension. This medicine should not be used if the Blood Pressure is normal due to the risk of slowing your heart rate (hypotension). This is bearing in mind that Nebivolol, a Beta blocker (a drug that also reduces heart rate), is also used as a doping agent. Such a combination is lethal.
3. Aspirin(Ascard 75): An antiplatelet agent used for primary or secondary prevention of stroke/heart attacks. In this case, they use this to prevent the strain on the heart or the probability of heart attack or stroke.
4. Letrozole: An aromatase inhibitor used to treat certain types of breast cancer. It effectively prevents the synthesis of estrogen. Athletes and bodybuilders use the anti-estrogen action of letrozole during the steroid cycle to reduce estrogen side effects, e.g. bloating due to excess water retention, male breast development and belly fat.
5. Carbegoline: A Dopamine receptor agonist that prevents the production of prolactin, mainly used to treat menstrual and fertility issues. It is assumed to improve testosterone production, and more dopamine means more physical aggression, translating to more challenging workouts.
6. Sildenafil: A phosphodiesterase-5-inhibitor initially designed for pulmonary hypertension but can be used off-label for Erectile Dysfunction (ED) due to its vasodilation properties. In addition to using it to prevent ED, bodybuilders use it as a pre-workout supplement to increase blood flow and oxygen delivery to muscles.
7. Ezetimibe: A selective cholesterol-absorption inhibitor used in the management of hypercholesterolemia.
8. Bodybuilders use milk thistle extracts to support a healthy liver and increase their muscles’ size.

With such a cocktail of drugs, the potential kidney damage has been underestimated! These are prescription-only medicines, which calls for tighter regulation and prudence from the custodians of drugs to promote safe and optimal use.

Today is World Patient Safety Day, and the theme is ‘Engaging patients for patient safety’. Part of improving patient safety is the prerogative to ensure that the correct information gets out there to the public. While the goal is to empower the patient and the public to be self-autonomous, it should not be lost on us that medicines are poisons if they are in the wrong hands or utilised for the wrong purposes.

The Global Patient Safety Action Plan 2021-2030 was adopted with a vision of “A world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere”. Given the perilous and precarious times we live in, Pharmacists must take affirmative action to be gatekeepers of the information consumed by the public in every small way. This may include demystifying wrong notions, ignorance, and assumptions by putting the correct information out there.

We are working together to make health care safer! Elevating the patient’s voice is, first and foremost, a call to advocate for urgent affirmative action for correct and proper Medicines Information Campaigns!

Pharmacists can provide specialised advice to athletes because of their advanced knowledge of drugs and being health professionals who are easily accessible to the public.

Happy World Patient Safety Day! (17th September 2023)

Written & compiled by: Maryanne Favour Ong’udi

References:

1.     Anabolic Steroid Misuse  NHS Choices. Available at: https://www.nhs.uk/conditions/anabolic-steroid-misuse/ (Accessed: 12 September 2023).

2.     Global Patient Safety Action Plan 2021-2030; World Health Organization. Available at: https://www.who.int/publications/i/item/9789240032705 (Accessed: 12 September 2023).

3.     Rochon, P.A. and Gurwitz, J.H. (1997) Optimising drug treatment for elderly people: The prescribing cascade, BMJ (Clinical research ed.). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127690/ (Accessed: 12 September 2023).

4.     Yee, K.C. et al. (2020) Pharmacists as a source of advice on medication use for athletes, Pharmacy (Basel, Switzerland). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151651/#:~:text=Pharmacists%20can%20potentially%20provide%20specialised,12%2C18%2C19%5D. (Accessed: 12 September 2023).