Archive for July, 2015

Bleeding to Death at Nursing Homes — warfarin

NHadlsA story in Pro-Publica (7/12/15) and reproduced in the Washington Post highlights the problems with anticoagulants when given in nursing homes.  The graphic at the left shows the magnitude of the problem — lots of patients in nursing homes get these drugs.  The next graphic shows data from North Carolina pinpointing the main culprit: WARFARIN.

NHerrorsInNCWhat is going on?  Well, warfarin is a tricky drug because it changes the body’s system to make the blood clot.  Some people tend to clot too much (and get clots in the brain, a stroke, and some people get clots in the lungs, a pulmonary embolus).  Those people are at risk of death from too much blood clotting.  So, health care providers prescribe an anticoagulant to make the blood clot less easily.  Unfortunately, this creates a state where people bleed easily.  It is indeed a situation “between a rock and a hard place“.

Warfarin is one of the most common of the drugs for this purpose.  It has the advantage of an existing antidote and it is inexpensive.  But, it requires frequent blood testing to keep the anticoagulant effects in a reasonably safe range.  Providers must order the tests and must change the dose according to the results.

Thrombin inhibitors are a new class of anticoagulants which have the same bleeding risks and are expensive.  Their claim to fame is that blood testing is not needed.  They also have the disturbing quality of not having an antidote if bleeding starts.  Taking all this into consideration, most providers choose the older drug warfarin.

The reasons for excessive bleeding in nursing homes are:

  1. Prescribers (not the nursing home staff) fail to order blood testing when they should and fail to adjust the medication as they should.
  2. Prescribers fail to stop anticoagulants when the risk of falling exceeds the risk of blood clotting.
  3. Pharmacists for nursing home patients are not as connected to their patients as they should be — usually the pharmacist is the safety net for bad prescribing — sadly, they are out of the loop.
  4. RNs in nursing homes have the training to catch medication errors but function as administrators and are not on the front line of care.  Thus, like pharmacists they are not performing the safety net function they might in hospitals or doctor’s offices.
  5. Elderly patients are the most prone to adverse drug events — for them, if a side effect is possible they will likely experience it.   It there is a risk of bleeding they probably will.

What should be done:

  1. State certification organizations should develop guidelines that require nursing homes and their prescribers to have a protocol for anticoagulation management — not every prescriber can be allowed to invent their own method — that’s the mess we have already!
  2. Nursing homes should use electronic means to track anticoagulants and the adherence to prescribing protocols.  This is not rocket science, those protocols (evidence based guidelines) and computer programs already exist!  So, USE THEM.
  3. Proactive patients and families should ask about the protocol that will be followed for warfarin in the nursing home — if there is no protocol SPEAK UP — show them a copy of this blog.

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Say “NO” to antibiotics but then what?

cougherKudos to Consumer Reports for the article on the over-use of antibiotics “How to Stop a Superbug” in the August 2015 issue.  One of the most common reasons people see primary care doctors is cough.  And, as it turns out, most of those coughs should NOT be treated with antibiotics.  Of course, it does not mean they do not need treatment — just not with antibiotics since the cause is usually a recent viral infection.  Antibiotics do nothing for viral infections.

Doctors who inappropriately treat a cough with antibiotics often do so just to get the patient out of the office as quickly as possible.  Statements like “could be early pneumonia” or “I hear some pneumonia” or “you have bronchitis” is the politically correct version of “you will get over it, take this pill and don’t bother me”.

So what is going on?  A virus irritates the lining of the bronchial tubes.  The tubes become inflamed and overly sensitive, causing the symptom of coughing.  Coughing is bothersome, it keeps people awake at night, makes noise at work and after a while it hurts the ribs and chest — it’s super irritating — please get rid of it!

The bottom line is that a virus infection causes a temporary form of asthma.  Doctors have hesitated to make that diagnosis because once you say “asthma” it is like a life-long diagnosis — in fact, it could have been a reason for an insurance company to deny coverage in the past.  So, by avoiding the “a”-word adequate treatment is not offered.  Anti-asthma treatment really works! and it is almost always a temporary treatment (unless the person really does have typical asthma).

Why a researcher would do such an experiment is not clear but they have compared the benefit of antibiotic treatment versus an asthma inhaler for “acute bronchitis” and found the inhaler works better — duh — treating a virus with an antibiotic is a placebo treatment.

Cough after a viral infection, particularly influenza, can last a long time, sometimes months, even though the virus itself is gone.  And, when people have a long-term cough other diseases need to be considered.  A cough that lasts for more than a few weeks usually needs to be evaluated with a chest x-ray as a precaution.

Many times a long term cough is the result of ineffective treatment — the failure to prescribe adequate inhaled medication to begin with.  Sometimes, it is the failure of the patient to have the prescription for the inhaled medication filled (it’s expensive) and sometimes it is a failure to take the inhaled medication correctly.

Very few doctors explain how to take an inhaled medication — it just takes too long, and they expect the pharmacist to do that.  Sadly, the pharmacy tech who hands out prescription has no idea how an inhaler should be used — and the pharmacist is not much better.  Proper technique (click on the link) is critical for the medication to work.

What inhaler is best? — there are several to choose from.  Check your insurance formulary for a combination product containing both a steroid and a bronchodilator.   There are no generics in this class of prescription drugs and that is another story!  Some choices include Dulera, Advair, and Symbacort (there may be others depending on what country you live in).

Again, thanks to Consumer Reports.  But, they did omit the obvious question for a cough:  if you don’t take an antibiotic for a cough, exactly what do you do?  If it’s mild, cough-drops and nasal decongestants are helpful, but if it is a bigger problem an anti-asthma inhaler is often a huge help.  Be proactive, tell you doctor you don’t want an antibiotic for your cough but you do want an asthma medication — bring this article with you.

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