Cutting prescriptions to size

Dr. K L Chowdhury

Preamble: Scientific advances in medicine combined with modern technology have revolutionized medical care. We are making rapid advances in the treatment of diseases heretofore believed to be incurable. We know how organ transplants and artificial prosthesis, robotic aids and chips inside the human body not only give a fresh lease of life to millions around the world but also make their lives worthwhile. As a result life span has shown a remarkable rise in the last four decades. But there is a price to pay for every blessing; ageing brings with it numerous new challenges. For example, what about a person who has no count of the drugs that have been prescribed for which he can’t find enough time in the day to sort out and swallow, leaving him not a moment free from them, not even a moment to eat, wash or sleep, far from some recreation or introspection.
Here is a case in point:
Case Report: A 70 year male, sought my advice on June 1, 2018. He had diabetes of 20 years, hypertension, coronary artery disease, bronchial asthma, and hypothyroidism. He had sustained an inferior wall myocardial infarction (heart attack) and a stent was put in place after angiography revealed a blocked right coronary.
He had come to seek my advice for a drop in hemoglobin which had been detected on a routine blood examination; it was a self ordered test.
Except for the anemia he seemed reasonably fit despite his multiple morbidities.
When I asked what drugs he was currently taking, the patient pulled a diary out from his handbag, and placed it on my table. It was a unique specimen; the whole page was filled with the prescription from top to bottom by his consultant, a senior medical advisor, under his signature and seal.
“Are you taking all these medicines at this point of time?” I asked in utter amazement.
“Yes, sir,” he sighed. “In fact, I have come to ask you if I need all these drugs. Generally, each month, my doctor repeats the same prescription except for a few alterations, mostly additions, for any new symptom that I might report. You see, my whole day is spent fishing the medicine cabinet for the pills and capsules; I often miss or repeat a dose I have already taken. I am confused which medicine to take at what time, weather before or after food, with water or milk or tea, whether together or one after the other. I have to drink a lot of water to swallow the pills some of which are so large they get stuck in my throat. I don’t get enough time for my routine work, for news paper or TV, and hardly any for a walk or for socializing. I can’t go anywhere for any length of time because I have to carry my medicine baggage or I will miss a dose. Besides the four insulin injections daily, I have to test my blood sugar once or twice to calculate the dose. I am not just a prisoner of my afflictions but worse, a prisoner of the medication that has been prescribed. I carry this diary with me to check what I have taken and what remains; it is like a holy commandment signed by my doctor, which I study more carefully than I ever studied my books when I was a student, and more intensely than I ever read the Gita or any scripture. This is no life. I have come to you with one hope, the hope of liberation from the numerous pills and capsules. Can you please cut this prescription to size?”
I liked that expression. in fact, I have been cutting prescriptions to size for all my life ever since I observed the pervasive tendency of medical professionals to over prescribe, often unnecessary drugs or drugs without authenticated benefits, even drugs that are counter productive or cross reacting and potentially harmful in different settings, and drugs for symptoms caused by other drugs.
Polypharmacy: I studied the entries in the patient’s diary. It was like a mini pharmacopoeia reproduced on that page. There were 30 drug items for daily consumption that included three injections of short acting insulin and one of basal insulin, a total of 36 tab/capsules per day, two inhalations twice a day of a twin combination and one inhalation of another, and two nasal sprays of a twin drug combination twice a day. It was mind boggling. I pitied the patient who spends a whole day sorting out which drugs to take at what time in what manner; I pitied the doctor who must have taken a full fifteen minutes just to write down the prescription. I pitied me for getting dragged into a breach of faith between a patient and his doctor. I said so to the patient but he pleaded with eyes that sought liberation. Yes, liberation from the burden of a humungous prescription.
I have often wondered about, and loudly decried (at the risk of annoying fellow professionals), the subtle and sometimes explicit compact between the medical fraternity, the pharmaceutical industry and the labs and imaging centers, each seeking their pound of flesh from the unsuspecting patient. In the process, doctors order (and some patients also self-order) a battery of tests even for trivial afflictions or no afflictions at all, prescribe a long list of costly and unwarranted drugs, and perform unnecessary interventions, flagrantly flouting the Hippocratic Oath, often exposing the patient to harmful, and potentially dangerous, consequences including death.
This present case is illustrative of polypharmacy that is the curse of current medical practice. I prefer to call it hyper-pharmacy. Does a fellow need the entire pharmacopoeia to live and sustain life? At what cost?
Risks and benefits: The most commonly reported definition of polypharmacy is five or more medications daily. But with longer life spans and multiple morbidities with ageing, like the case under review, more and more drugs need to be prescribed, so we are yet to evolve a consensus on the distinction between appropriate and inappropriate polypharmacy. However, polypharmacy is associated with adverse outcomes including gastrointestinal upsets, falls from orthostatic hypotension (fall of BP on standing up), adverse drug reactions, and mortality. It is no brainier that the risk of adverse effects and harm increases with increasing numbers of medications. Older patients are at even greater risk of adverse effects due to decreased kidney and liver function, hearing and visual impairment, reduced cognition and limited mobility and unpredictable drug responses. Often, an adverse drug reaction is misinterpreted as a new medical condition, for which another drug is then prescribed, placing the patient at risk of developing additional adverse effects. This is a cascading effect.
One of the primary goals of the doctor must be to avoid polypharmacy or institute rational polypharmacy after a careful and detailed assessment of the various afflictions of the patient, of current medications and all recent medication changes. A new medication should be added only when there is a clear indication for its use, keeping in mind that polypharmacy can adversely affect the ability of an older adult to adhere to his or her medication regimen. All medications should be assessed for risks and benefits and the final combination of medications should be based on benefits outweighing the risks. Most importantly, the doctor needs to look at the patient not merely as a sum of his afflictions, not merely as a vehicle of his organs and systems, but in totality – body, mind and spirit – as a whole, a dynamic human being with a soul, the central focus being on improving the quality of life and not merely prolonging the misery.
Epilogue: So what about the patient who came to seek my guidance? Well, he was anemic, which on investigation was the result of occult bleeding from the stomach caused by the use of twin blood thinners in his prescription. His blood pressure was low from three blood pressure drugs. He gave history of frequent hypoglycemia (low blood sugar) because besides the four insulin shots a day he was also consuming three oral drugs for diabetes. He was receiving too many anti-angina drugs (four items) even as he hardly complained of angina; he was also taking a diuretic (that causes increase in uric acid) at the same time receiving a drug for lowering uric acid. He was also taking one of the so called ‘gas’ capsules , besides large doses of calcium and multivitamin supplements which he had been taking ever since he remembered. His asthma was seasonal, yet he was on large doses of inhalers and nasal sprays.
I clipped his prescription and reduced it to eleven items that I thought absolutely necessary. It is ten months since the patient saw me the first time. He has been reporting regularly, and is fairly well controlled in all parameters, happy with life that has been liberated from the slavery to medications and tests, now finding enough time for his family and friends, for prayer and recreation. “I am a changed man,” he remarked when I saw him last week.
If we can’t make life better for a patient let’s not make it worse.