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From: B. Harris)
Subject: Re: Chronic coughing
Date: 12 Apr 1997

In <> bacal tommy

>Steve Hoffman wrote:
>> A friend of mine is being treated for Chronic Fatigue, and is taking a
>> number of drugs. She's having problems with coughing all night long,
>> but has no problem with this during the day. She's wondering if this
>> could be due to one or more of the drugs.
>> She takes the following in the morning: Estrace, Provera, Synthroid,
>> and Miacalcin. And she takes these at bedtime: Norvasc, Paxil, Zantac,
>> Zocor, Zyrtec, Melatonin, and Nasocort Spray. Any ideas on the coughing
>> problem? (Sure seems to me that she's over-medicated in general!)
>> Thanks!
>there's no doubt in my mind she's overmedicated! and by the way, did she
>consider the possibility she's suffering from a psychosomatic disorder?


   I hate to say this, but there's no way to tell whether or not
somebody is "overmedicated" by simply looking at the length of
their medication list. If it was, insurance agencies could save a
lot of money by simply siccing a computer program on their
patients' doctors, without anybody bothering to do any real
thinking.  Alas, Nature isn't so fair as to dole out diseases
equitably so that no one person needs to be treated for more than
a certain maximum number of problems at once.  Rather the
opposite: when it comes to disease, it seems that to whom much is
given, more will be added unto.  (Such is the Kingdom of
Heaven...).   Thus, if the lady in question has a competently-
diagnosed disease causing big risks or big problems in her life
to go along with each of those drugs, then she could possibly
benefit from each one of them.  And from all of them
collectively.  Contrary to popular opinion also, there isn't any
maximum number of different drugs which a person can take, before
adding a new one requires that somebody find another to take
away, in order to maintain health.  Insurance companies only wish
this was true.

   Which is not to say that the number of POSSIBLE side-effects
and bad drug interactions does not rise at least geometrically
with the number of drugs used.  Of course it does.  That's what
"drug holidays" are for.  Most of the drugs in the above list can
be stopped for a couple of weeks without harm, with the possible
exception of the Norvasc, which could certainly be exchanged at
the same time for another anti-hypertensive-- for example,
another calcium channel blocker of a different subclass. (Of
course, you want to stay away from ACE inhibitors while working
up any chronic cough-- no point in curing a symptom by doing one
thing, only to cause it again by doing another...)

   And I do suggest a holiday from ALL the drugs.  It's unlikely
that the hormones in the list are causing this problem, but you
never know.  No medication is 100% pure, and people can get
allergic reactions (which include cough) even to excipients
(nonactive stuff in pills or formulations) and impurities.  And a
drug holiday is helpful even for some people on thyroid
medication, I find, since some fraction of them were put on the
drug for unclear or bad reasons, and really don't need it
(hormone levels measured a couple of weeks after stopping the
thyroid tells the tale, and stopping the hormone for this length
of time causes no harm, even for someone who needs it).

    After a successful drug holiday (patient feels much better),
drugs can be added back one at a time until you find which one is
causing the problem.  Or with a large number of drugs, you can do
a "binary search," for the bad one, by adding back drugs in
batches, then sub-batches.   After an unsuccessful drug holiday
(no change in symptoms at all, indicating that meds are not the
problem), you can add the meds all back all at once, and look for
pathology.  Cough at night is a classic symptom of early "left-
sided" congestive heart failure, and a good physical exam and
perhaps a cardiac rest echo (to look at left ventricular function
and compliance) might be helpful.  And also pulmonary function
tests to look for active asthma and other obstructive lung
disease which might cause dyspnea while supine.  From the
medications the lady is on, it looks like she's already being
treated for allergies and high cholesterol, so neither of these
possibilities looks completely out of the question.

                              Steve Harris, M.D.

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