Some points to remember about drug therapy
March 1, 1999 3 minutes read
Some points to remember about drug therapy
The science behind CHF medication may be getting even more sophisticated, yet experts say keeping prescription strategies simple for your patient is as important as ever. Here are some guidelines worth revisiting, says Sean M. Jeffery, PharmD, assistant clinical professor at the University of Connecticut’s School of Pharmacy.
These tips are adapted from a published report you might find useful. (See Journal of Clinical Epidemiology 1992; 45:1,045-1,051.)
o Is there an indication for the drug?
A recent recommendation for treating heart failure published in the American Journal of Cardiology calls for four different prescriptions for patients:
— a diuretic;
— a beta-blocker;
— an ACE inhibitor;
— digitalis.
o Is it effective?
Recent reports have zeroed in on this question lately, especially for angiotensin II receptor blockers and Digoxin.
o Is the dosage correct?
"Start low, and go slow" is especially true for treating elderly patients, Jeffery says. He notes that he recently saw a CHF patient require hospitalization because she began beta-blocker therapy at a dose that was too high.
o Is it prescribed properly?
Does the patient know how to take the prescriptions?
o Are the directions practical?
Jeffery says he sees a lot of confusing regimens for patients to follow, particularly with diuretics. He notes that even if you "start low and go slow," make sure you reassess therapy and titrate as needed. Studies show compliance can decline significantly when dosages are more than twice a day, he says. (For more on compliance issues, see CHF Disease Management, January 1999, pp. 8-12.)
o Is the duration of therapy acceptable?
Heart failure patients probably will be taking their medication for the rest of their lives. There are some considerations, however, such as if the patients in end-stage disease with renal insufficiency still need an iron supplement.
o Try to choose the least expensive medications where appropriate.
o Watch drug interactions.
For example, bradycardia can occur from too much beta-blocker and Digoxin combined.
o Watch clinical disease interactions.
For example, Jeffery says beta-blockers may blunt a hypoglycemic response in diabetic patients.
o Watch out for duplication.
If patients are being treated by more than one doctor at a time, there’s a greater chance of duplicate prescriptions.
"You’d be amazed," Jeffery says, noting that he has seen patients taking two of the same diuretic or two beta-blockers. Beside the extra cost for the redundant medicine, the chances for side effects escalate.
Drug decisions affect at least three groups of people
This strategy of using guides (see story, above) to gauge decisions about what a physician prescribes is called evidence-based medicine, says Frank Ascione, PharmD, PhD, associate professor of pharmacy administration at the University of Michigan in Ann Arbor. It’s a good way to check for quality of care. When it comes to costs, however, you’ll need to consider all who have a stake in your clinical decision.
Each drug decision a doctor makes affects at least three different groups of people — the patient, the doctor, and the organization paying for the service.
The drug backed by new clinical trials for treating a condition may be the doctor’s choice, and in turn, the patient’s choice. But the payers may not agree with the decision because it goes against a formulary or accepted practice.
"Physicians have to understand these factors and defend their position," he says. "Individual physicians need to make the best possible decisions and be able to articulate that to the people who are paying the bill."
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