Complicated dosing may deter physicians
Given the overwhelming evidence in favor of ACE inhibitors, why might physicians hesitate to prescribe them? Randall Stafford, MD, PhD, instructor in medicine at Harvard Medical School and Massachusetts General Hospital, and Prakash Deedwania, MD, chief of the cardiology division at the Veterans Affairs Medical Center in Fresno, CA, point out several possible reasons:
· Physicians may be unfamiliar with the evidence or with the contraindications. Deedwania says that with so many studies and national guidelines promoting the use of ACE inhibitors, this one shouldn't be an excuse. As for contraindications, the benefits outweigh side effects as well as the extra time spent researching possible problems. Besides, all medications have the potential to create difficult situations.
· Patients may have comorbidities that make dosing more complicated. Physicians may be scared to use the drugs when there is underlying kidney disease or other illness. "Physicians are hassled for time, and they want to prescribe drugs that are easier," Deedwania says. And there's too much concern over exacerbating kidney disease, he says. In the early stages of kidney disease, more than likely kidney function will actually improve.
· Patients may not want to live with the cough that sometimes comes along with the drugs. "If ACE inhibitors only had a minimal benefit, there would be no reason to ask a patient to tolerate that kind of side effect," Stafford says. "But an awful lot of patients probably get taken off ACE inhibitors because of a very mild cough that they probably could live with." Deedwania points out that CHF itself causes coughing, so it's hard to say if it's the ACE inhibitor's fault.
· It might be hard to get patients to comply, since the preventive nature of the drugs means they might not feel better immediately. "People might be leery of causing side effects with a medication when, on a next-day basis, it's difficult to see that it's doing some good," Stafford says.
· Digoxin and lasix have a traditional role in the emergency department, and that mentality may carry over into CHF treatment. "Some physicians view the role of digoxin and lasix in an acute situation as somehow making them better medications," Stafford says. "But the AHCPR guideline says ACE inhibitors should be first-line. Diuretics and digoxin should be reserved for people who don't get the maximum benefit on ACE inhibitors alone."
· Prescribing ACE inhibitors is just not a priority. "Physicians are very busy trying to meet the expectations of their patients," Stafford says, "and if they spend too much time on issues outside of the reason the patient came in, some patients get upset."
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