Doctor doing a colonoscopy for elderly man while a nurse is comforting a patient.
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The U.S. health system often is plagued by too much of a (sometimes) good thing. Doctors order a test or treatment and then continue them for the rest of the patient’s life, whether they really need them or not. And, often, they are ongoing for no good reason, despite potential risks to patients.
The April 6 Journal of the American Medical Association includes important research questioning the benefits for some older adults of two common interventions: routine screening colonoscopies and the drug levothyroxine (Synthroid), a frequently prescribed medication that increases low thyroid hormones.
It is important to note that both can be extremely beneficial and the new research does not suggest they never are appropriate for older adults. But these studies conclude it may be inappropriate for physicians to continue them without carefully reassessing their risks and benefits for seniors.
Colonoscopies remain the best way to identify and remove polyps from the colon. By doing so, they can significantly reduce the risk of colon cancer and of dying from the disease. They may be more important than ever for younger people, whose risks of colon cancer seem to be increasing.
A 2022 essay in Harvard Health presented the standard medical view: “The bottom line: Should you undergo screening colonoscopy or not? Yes! Unequivocally, yes.”
But for many older patients, the better answer may be ‘it depends.’”
Like almost everything in medicine, colonoscopies come with their own risks. They may, rarely, result in serious bleeding and some patients may suffer from severe post-procedure discomfort or react badly to anesthesia.
Preparing for the procedure remains unpleasant and the cost is significant. On average, Medicare pays about $650 for each screening colonoscopy in a surgery center and about $1,100 in a hospital. An uninsured patient can spend $2,000 or more.
And there now are non-invasive screening alternatives, such as testing a stool sample, that are appropriate for many people.
Earlier studies found little value in screening colonoscopies for those age 75 or older whose earlier tests showed no precancerous polyps. But the new JAMA study found even some older adults whose earlier tests did find polyps may not benefit from another procedure.
In their landmark study, Dr. Samir Gupta at the University of California at San Diego and colleagues studied colon cancer incidence and death rates from the disease after 10 years among roughly 90,000 (mostly male) veterans who had a colonoscopy before age 75.
They found chances of both colon cancer and related mortality after age 75 were very small, especially compared to other causes of deaths. For example, Gupta and colleagues reported colon cancer rates among those with an earlier positive test were 1.1% while those with a prior negative test were 0.7%. Death rates from colon cancer were 0.5% for those with an earlier positive test and 0.4% for those who had no earlier polyps.
By contrast, nearly half of those in the study died from other causes. Keep in mind that since this study overwhelmingly looked at men, it is not clear if the results would be the same for women.
Still, the results support earlier recommendations by the US Preventive Services Task Force and the American Cancer Society that urge doctors and patients older than 75 to reconsider routine colonoscopies.
The lesson for both doctors and their older patients: While some older patients should continue to receive colonoscopies, the test may not be necessary or worth the risks for most men older than 75.
The story is similar for the low-thyroid drug levothyroxine. It is absolutely beneficial for many patients, but those age 60 and older taking low doses should talk to a doctor about whether they need to continue taking this drug.
This research, also published in JAMA (paywall) was done by Dr. Janneke Ravensberg and colleagues at Leiden University Medical Center in the Netherlands. They followed a relatively small sample of patients, about 360 older adults. But they found that about two-thirds of those taking a dose of 50 micrograms (mcg) or lower could gradually stop with no negative effects one year later.
Like colonoscopies, levothyroxine often is helpful. It is a low-cost drug that helps increase the production of important hormones when the thyroid is not working properly. Low thyroid levels can result in fatigue, constipation, depression and, in very serious cases, heart disease or coma.
However, like all drugs, levothyroxine comes with risks. It can cause nausea, diarrhea, or muscle cramps or, more seriously, bone fractures, atrial fibrillation, and cognitive impairment.
The generic drug is inexpensive, usually $12 or less a month. But as many as 23 million Americans take it, making it one of the most commonly prescribed drugs. It often is prescribed for what’s called subclinical hypothyroidism, which is to say a blood test showed some signs of low thyroid hormones but not conclusive evidence of disease.
One 2021 study found that as many as 90 percent of those taking levothyroxine may not need it. Many are older adults who take low doses.
In the Netherlands research, about one-quarter of all those in the study gradually stopped the drug with no ill effects. Among those taking a low dose, 64% successfully discontinued the drug.
The bottom line: Many older adults may never have needed the drug at all. But if they were prescribed a low dose of levothyroxine in the past, after age 60 they and their doctors should reconsider whether to continue.
An important caveat: Patients who do discontinue levothyroxine should do so gradually, and under the supervision of their doctor.
Mindlessly taking unnecessary drugs or repeating low-value tests creates needless risks and are yet another reason why the US spends so much on health care. These interventions are not free, either medically or financially. And doctors and patients need to give them more thought.
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