Living a healthy lifestyle of good nutrition, regular exercise, reducing stress and sleep are all important to manage conditions like diabetes, heart disease and cancers. However, sometimes that isn’t enough and medications are needed.
For the past year I’ve been taking two medications (a beta blocker- bisoprolol, and a statin- rosouvastatin) religiously. Working in a heart clinic, I know this isn’t much. Some patients take up to 10 medications at multiple times per day. That scenario is becoming increasingly common as more and more people have multiple chronic diseases.
A couple of weeks ago I got a taste (poor choice of words?) of managing four medications with repeated dosing for a week. I had a severe throat infection that required IV antibiotics in the emergency room and I was also prescribed an oral antibiotic (metronidazole- two tablets twice per day). After two days of IV doses, another antibiotic, clindamycin, was given to me. This one at two tablets three times a day.
The first thing that strikes me is the names of these medications. It’s as if the more syllables the better. Who thinks up these names? They sound more at home in a Star Trek episode than in my mouth, right up there with the Klingons and Cardassians (no relation to the Kardashians- I think). Right from the start this becomes a barrier to patient-provider communication. When patients are asked what medications they’re taking, many respond saying something like the small red pill or blue pill as they can’t remember or pronounce their medications. In this case, carrying a list in your wallet/purse with the doses can be helpful.
Taking one’s medication as prescribed is extremely important to improving one’s health whether taking a temporary one like an antibiotic or a lifelong blood pressure lowering one. In the realm of heart disease, poor medication adherence is a key determinant to early hospital readmission after a heart attack. But it’s not always easy to remember to take them and as the number and complexity of the medication regimen increases, adherence becomes harder. As a possible solution to this, my group is part of a multi-country study to test a polypill. This one pill is a combination of blood pressure and cholesterol lowering agents and aspirin that could replace five separate pills, improve adherence and reduce costs.
Understanding what the medication does and why it’s needed can help with patient adherence. Up until we’re middle aged (or older), the only medications that any of will have taken are antibiotics and others that are used for a short time and then stopped. When it comes to medications for blood pressure, shortness of breath, blood sugar, and the like, these ones are most likely going to be taken for the rest of that person’s life. This can often trip people up. Some patients taking a cholesterol lowering medication stop it every time their cholesterol values improve. As a result, their cholesterol goes back up. Talking to them, it became clear they thought the medications acted like an antibiotic and once the cholesterol was within target it would stay that way.
It would be nice to think that health professionals will tell us all that we need to know about our medications but that isn’t the case. As patients we need to ask questions. Sometimes we think that a doctor or nurse can’t be wrong, but they can be. They’re human too. It can definitely be intimidating at times talking to a health professional. It’s almost as bad as talking to someone in your IT department when your computer breaks down (“No, I’m serious,” I would protest. “I was typing away and the screen went blue and shut off.” The IT person just shakes his/her head in disbelief.).
After the second dose of my IV antibiotics, the ER doctor came over and gave me a prescription for an oral antibiotic. I looked at the prescription and asked what it was. When the doctor responded I told him I was allergic to that medication. He hadn’t asked about allergies and at first I just assumed it would be in my chart (guess it wasn’t, he also got my name wrong on the prescription, so that had to be fixed as well).
As I was already taking an oral antibiotic prescribed the day before, I wanted to confirm that I had to take both. I’ve never had to take two antibiotics. I know from talking to other patients that sometimes it’s not clear when you go into the hospital and are prescribed new medications if the new ones are replacements or in addition. You can imagine that lying in bed following a heart attack your mind might not be the clearest. Some medications don’t work well together and taking multiple medications (called polypharmacy) can lead to adverse effects if this isn’t clarified.
Just the other week, The US FDA released a warning for heart patients not to take the antibiotic clarithromycin, as it is associated with a higher risk of death. By the time I came across this, I had already finished my antibiotics but I couldn’t help but think that the antibiotic I was taking (clindamycin) sounds quite similar to clarithromycin.
This concern about adverse reactions from polypharmacy has led to a growing field of research into medication reconciliation in which health care providers and organizations are looking at ways to reduce problems. One such program has pharmacists follow-up patients at home to go over their medications. In my case, after interrogating the ER doctor with questions, I finally understood that I needed to take both antibiotics at the same time.
Since I was only on these antibiotics for a week I didn’t find it too problematic. I had to bring one of them to work to take the mid-day dose, which wasn’t too bad. But it did make me reflect on the challenges I’ve seen patients have in managing their own medications. Fortunately there are a number of aids people can use such as pill boxes to having the pharmacy put your medications into pill bubble packs (although this can be quite pricey).
In this digital age, you can also upload a medication reminder app to your phone. Some may be effective but many are not and so one needs to be vigilant to see if they are right for you. Health care organizations and insurers are starting to use programs that support adherence as well. In the field of HIV, which has some of the most complex medication regimens around, the use of automated text message reminders has proven to be of great value. We’ve built on this work and we will soon know the results of our pilot study of using text messages to improve adherence in heart patients.
For me, back to taking only my two medications, I use a low tech strategy. I have them on my bathroom counter so that I see them when I brush my teeth in the morning and again at night. It’s not foolproof but it works 99% of the time.
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