Posts Tagged over prescribing
Many patients take too many medications which leads to unnecessary side effects, drug interactions and high cost. Yet physicians sometimes fight just to get patients to take necessary medications. Two examples:
- Provider: How many medications are you taking?
Patient: Including vitamins I think fifteen.
Provider: What? I only have two medications on my list.
Patient: I restarted all the medications I was taking before you hospitalized me plus all the new prescriptions from when I left the hospital and I added some vitamins.
- Patient: I stopped that medication because I thought it was causing my hair to fall out.
Provider: Your heart medication does not cause hair to fall out. And, even if it did you could die without it.
The medications you take should be reviewed at each visit so you and the provider consider which are truly needed and why. The provider who gives the patient a prescription is responsible to make sure there is no interaction or duplication with ongoing treatment. Yes, that means cardiologists and dentists also. A proactive patient should simply ask, “Is that new medication compatible with all of my existing medications and does it replace one of the existing medications?”
The highest risk situation for evaluation of medications happens when alternate providers become involved. Like a hospital doctor, an ER doctor or a specialist. They tend to add medications without fully considering the existing medications, often thinking the primary provider will resolve any drug issues — too bad when a fill-in primary provider steps into the mix.
An article in the Washington Post January 28, 2017 by Dr. Ranit Mishori advises the following questions for providers and patients to consider together about medications:
● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?
Elderly patients are taking too many drugs. And, in most cases the drugs can be stopped. This surprising idea was highlighted by Dr. Ezekiel J. Emanuel in his New York Times article 11/22/15. He backed up his statements with a study from 2010 (JAMA). The figures that follow are from that study.
The first figure is the logic diagram for stopping medications in elderly patients who have several chronic diseases. The second figure is the list of medications that were stopped in the study. Only 2% of the stopped medications eventually had to be restarted. The cost savings alone is huge and the reduction in the risk of side effects is likewise tremendous. “Less is more”.
Health care providers often prescribe drugs intended for younger healthier patients to older sicker patients. Often the drug testing originally done to approve drugs excludes older sicker patients due to the risks of side effects. A drug might add many years of life to a 50 year old but that’s not likely for an 80 year old with multiple problems. In fact, over medicating elderly patients may hasten death — this has been proven in many studies.
Dr Ezekiel suggests asking the following questions to the health care providers who prescribe medications, tests or treatments to elderly patients (or perhaps any patients):
- What difference will it make?
- How much improvement is expected?
- How likely and severe are the side effects?
Evaluate the answers carefully, if the answers are: small difference, not much improvement, and fairly likely side effects then perhaps that drug, test or treatment is not needed.
Dr. Emanuel favors the advice of teaching hospital doctors like him, but it’s just not practical or necessary for patients to get a university consultation. Stopping medications is not rocket science. As the graphic says, it may be better for many elderly patients to get “hugs not drugs“.