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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Despite the literally dozens of new drugs that enter the market annually, most clinicians in primary care rely on a relative handful of tried-and-true agents. Yet new uses and surprising benefits for these older drugs continue to be found. Dr Douglas Paauw, professor of medicine at University of Washington, provides information on seven that you should know.

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Metformin: Cancer Outcomes and Prevention

Metformin is the most commonly prescribed oral hypoglycemic, because of its proven efficacy, low cost, minimal hypoglycemia risk, and weight neutrality. But multiple studies have suggested another possible benefit: a reduction in cancer incidence and mortality.[1] A nested case-control study involving more than 20,000 women with type 2 diabetes concluded that metformin use for > 5 years was associated with a reduced risk for breast cancer (adjusted odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.82).[2] And a 2017 meta-analysis involving almost 9000 patients taking metformin documented a reduced risk for colorectal adenoma (pooled OR, 0.76; 95% CI, 0.63-0.92).[3] Metformin may also slow progression of and improve survival in some cancers, including head and neck,[4] ovarian,[5] pancreatic,[6] and lung.[7] Although this effect has not been consistently demonstrated in animal models or epidemiologic studies,[8] much research is under way on the potential antitumor effects of metformin.

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Another Role for Losartan

An added benefit of using losartan as an antihypertensive medication in your patients with hyperuricemia, is that it lowers serum uric acid.[9-12] Losartan has urinary alkalinizing effects, which enhance excretion of uric acid and reduce the risk for uric acid crystal formation.[11] A population-based case-control study of patients receiving agents for hypertension found that losartan use was associated with a lower risk for incident gout.[13] Losartan is the only angiotensin II receptor blocker that demonstrates a significant reduction in uric acid levels, and it seems to be safe and effective in patients with hyperuricemia.[12]

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Gabapentin for Chronic Cough

Chronic cough is an extremely common problem and very difficult to treat. Over 90% of patients with chronic cough have upper-airway cough syndrome, asthma, nonasthmatic eosinophilic bronchitis, or gastroesophageal reflux disease, alone or in combination.[14] Unfortunately, though, there will be patients who do not respond to treatment for these conditions and in whom an alternative diagnosis cannot be found. So, what’s next? Cough suppressants have little evidence for efficacy. Surprisingly, the neuromodulator gabapentin has been shown to reduce cough frequency and improve quality of life.[15] A 10-week, placebo-controlled, randomized, double-blind trial of 62 patients with refractory chronic cough lasting > 8 weeks found that gabapentin significantly improved cough-specific quality-of-life (number needed to treat, 3.58).[16] The most recent chronic cough guidelines endorse gabapentin for chronic cough as an appropriate option in patients who have not responded to therapeutic trials for those common causes of chronic cough noted above.[17]

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Metoclopramide in Migraine

The antidopaminergic agent metoclopramide is an effective option for acute migraine therapy. Patients with migraine often have gastroparesis as part of their migraine attack, a likely cause of the nausea common during these events. As a promotility drug, metoclopramide can improve this gastroparesis, and also improve absorption of oral medications.[18]

Metoclopramide may be useful as adjunctive therapy for migraine. In a double-blind, randomized, crossover study of triptan nonresponders, patients reported meaningful relief in 63% of migraines treated with the combination of sumatriptan and metoclopramide compared with only 31% of migraines treated with sumatriptan alone.[19]

A recent review of migraine patients treated in emergency departments concluded that metoclopramide should be used more frequently over opioids as first-line therapy of acute migraine.[20]

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Thiazides and Osteopenic Fractures

Thiazide diuretics reduce urinary calcium excretion and may also lead to improvements in bone density. In the Framingham study, thiazide users had a decreased risk for hip fracture, a protection that was only conferred while the patient was on thiazides.[21] Randomized trials conducted since the Framingham study have shown that thiazide diuretic use preserves cortical bone density.[22,23] This benefit of thiazides is worth considering when weighing antihypertensive therapy choices.[24]

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Topical Nitroglycerin for Anal Fissures

Nitroglycerin is most commonly used to prevent or treat anginal attacks. But topical nitroglycerin also has some interesting noncardiac uses, including treatment of anal fissures.[25-27] High anal sphincter pressure is known to reduce blood flow to the area, and by decreasing this pressure, topical nitroglycerin improves local blood flow. The US Food and Drug Administration approved nitroglycerin ointment 0.4% for the treatment of moderate to severe pain associated with chronic anal fissures in 2011.

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

Topical Nitroglycerin for Tennis Elbow

Topical nitroglycerin has also been shown to be an effective treatment for lateral epicondylosis, sometimes referred to as "lateral epicondylitis" and more commonly termed "tennis elbow."[28-30] In a randomized controlled trial, 90% of patients treated with topical glyceryl trinitrate (GTN) reported successful treatment, whereas no patients in the placebo group reported good or excellent results.[28] This statistically significant difference in outcome was still present at the 6-month follow-up. Use of GTN patches has been shown to decrease pain and improve function in patients with symptoms of lateral epicondylosis.[30]

A recent systematic review[31] found that topical GTN for up to 6 months may also be a useful adjunctive treatment for tendinopathies.

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

The Wonders of Spironolactone: Part 1

Spironolactone has developed more prominence over the past two decades. The RALES trial[32] found that spironolactone in combination with standard therapy substantially reduced risk for morbidity and death in patients with severe heart failure as a result of left ventricular systolic dysfunction. Over the past decade, it has taken a larger role in the treatment of refractory hypertension.[33,34]

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

The Wonders of Spironolactone: Part 2

Owing to its antiandrogenic effects, spironolactone has also been used in women for the treatment of hirsutism,[35] female pattern baldness,[36] acne,[37,38] and dermatologic signs of polycystic ovarian syndrome (PCOS).[39] The data are strongest for hirsutism and PCOS, but positive studies and established practice for treatment of acne and female hair loss exist.

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10 Little Known Uses for Common, Everyday Drugs

Douglas S. Paauw, MD | December 3, 2018 | Contributor Information

The Wonders of Spironolactone: Part 3

Spironolactone blocks aldosterone, a proinflammatory substance, and suppresses cytokine production. Two recent trials have examined its potential therapeutic effect in osteoarthritis. A prospective, randomized study of 200 patients who met American College of Rheumatology criteria for knee osteoarthritis and had new-onset knee effusion concluded that low-dose spironolactone was superior to ibuprofen, ice, and placebo, with 66% of treated patients achieving complete resolution of effusion.[40] However, another randomized, placebo‐controlled, double‐blind trial of older adults with symptomatic knee pain due to osteoarthritis concluded that the agent did not improve pain or physical function.[41]

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