- Email: [email protected]
Polypharmacy
DISSECTING ROOM
Doctoring the risk society
Mightier than the sword
Polypharmacy “I’m not taking all these tablets. You’ll have to come and tell me which ones I really need to take.” Thus was I summoned to the bedside of a 95-year-old lady, recently discharged from hospital. This was her third admission in the past 12 months—and my third summons to sort out her medication. Each time she has emerged from hospital with a carrier bag full of drugs. A barely legible carbon copy of her discharge summary (whatever happened to the information superhighway?) revealed that she is supposed to be taking an angiotensin-converting-enzyme inhibitor, a  blocker, a diuretic, a statin, a low-dose aspirin, a calcium and vitamin D combination, as well as her long-standing thyroxine, the occasional paracetamol, and nitrazepam (her faithful “moggies”, still getting her off to sleep 30 years after her husband died). Despite recent cataract surgery, she can scarcely read the labels on these medications. With her arthritic fingers, popping pills out of foil wrapped cards is not much easier than opening child-proof bottles. She finds the dosette box helps a bit, but it is still very fiddly and easily spilt. The aim of many of these medications is to prolong life—by reducing blood pressure, cholesterol, the risk of heart failure, thrombosis, or fracture. But it only takes a brief inquiry to confirm that she has no desire whatever to extend her life. She is very frail but fully compos mentis. When I recently congratulated her on her birthday, she told me she wished that she hadn’t lived so long. All her friends and most of her relations have died and she can no longer get out and about as she used to. A few of my younger patients have recently inquired whether I can yet prescribe the so-called polypill, a cocktail containing many of the drugs prescribed separately for my elderly patient. This pill has received some publicity after a trial suggested that it can dramatically reduce the risk of coronary heart disease and offer the promise of significantly increased life expectancy (BMJ 2003; 326: 1419–24). Perhaps if I introduced these patients to my frail old lady they might reflect that improving the quality of life is more important than increasing its duration.
Mike Fitzpatrick e-mail: [email protected]
1340
utumn is back to school time. My children get fancy new backpacks, insulated lunch sacks, and I usually throw in a drug company pen for good measure. This is a familiar ceremony around our house, since I frequently give these pens to my children if they are disconsolate or need a nice pen for school. The nicer quality drug pens are stashed in a plastic candy jar. These are the ones that are heavier, shinier, or somehow more notable in appearance than the cheaper ones. The jar was also a drug company gift, but I have long since disposed of the candies it originally contained. My daughter looked at several likely candidates that had eye and hand appeal, but bypassed them in favour of a garish plastic pen adorned with a bright yellow fire hydrant at the end of the clicker to signify the many fires of indigestion that the gastric acid suppressor could put out. After my daughter had her turn, I couldn’t let my son get short-changed so I repeated the process with him. He selected a pen with a burnished metal barrel of deep blue emblazoned with the name of an antidepressant. Perhaps it signified the myriads of people who could be saved from feeling blue by the drug, or maybe the manufacturer thought it would look snappy in the pocket of the doctor’s white coat, or that my fourth grader could swap it for a really awesome Pokemon card. My receptionist’s son is in college and the campus intelligence I received from this source indicated that better quality Viagra pens were being sold on college campuses for $50. I suspect that the market for Viagra pens and Pfizer stock have both corrected by now, but you never know. I have stealthily observed that our Viagra sales representatives have different qualities of pens. The doctors in my
A
office that these salesmen perceive as their heavy prescribers receive a very solid and impressive metal pen of about US$3–4 in value, perhaps to signify all the unhappy erectile dysfunction suffering they were going to relieve. The less frequent Viagra prescribers, like myself, only got an ersatz plastic pen that cost about a quarter. When I was presented with this flaccid token of pharmaceutical gratitude, I smiled graciously and said “thank you” but deep inside I wanted one of those more potent pens. Although I surely would have been given one had I requested it, I was too embarrassed to ask for it, just like many Viagra users. I consoled myself silently with the thought, “who really wants a fancy pen with a drug company ad on the side?” A cardiologist colleague was given a fancy Mont Blanc from a pacemaker manufacturer. I know I can’t even aspire to achieve that level of drug company fawning. My children do not know this, but I have another top secret stash of drug company pens. These pens are special because they have the names of drugs that have been removed from the market. As soon as I learn the Food and Drug Administration is recalling a drug, I quickly check my office to see if I have a pen that bears the name of the drug that has been honoured with this dubious distinction, and I induct it into my “Recalled Drug Hall of Fame”. The last honoree was cerivastatin. What I’ll eventually do with these relics, these plastic mementos of failed therapeutics, I haven’t decided. Perhaps in my old age I can open a museum. Every time I add a pen to this elite collection, I remind myself of the truth of the old adage, “you have to use the new drug while it still works”. Larry Greenbaum
THE LANCET • Vol 362 • October 18, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Doctoring the risk society
Mightier than the sword
Polypharmacy “I’m not taking all these tablets. You’ll have to come and tell me which ones I really need to take.” Thus was I summoned to the bedside of a 95-year-old lady, recently discharged from hospital. This was her third admission in the past 12 months—and my third summons to sort out her medication. Each time she has emerged from hospital with a carrier bag full of drugs. A barely legible carbon copy of her discharge summary (whatever happened to the information superhighway?) revealed that she is supposed to be taking an angiotensin-converting-enzyme inhibitor, a  blocker, a diuretic, a statin, a low-dose aspirin, a calcium and vitamin D combination, as well as her long-standing thyroxine, the occasional paracetamol, and nitrazepam (her faithful “moggies”, still getting her off to sleep 30 years after her husband died). Despite recent cataract surgery, she can scarcely read the labels on these medications. With her arthritic fingers, popping pills out of foil wrapped cards is not much easier than opening child-proof bottles. She finds the dosette box helps a bit, but it is still very fiddly and easily spilt. The aim of many of these medications is to prolong life—by reducing blood pressure, cholesterol, the risk of heart failure, thrombosis, or fracture. But it only takes a brief inquiry to confirm that she has no desire whatever to extend her life. She is very frail but fully compos mentis. When I recently congratulated her on her birthday, she told me she wished that she hadn’t lived so long. All her friends and most of her relations have died and she can no longer get out and about as she used to. A few of my younger patients have recently inquired whether I can yet prescribe the so-called polypill, a cocktail containing many of the drugs prescribed separately for my elderly patient. This pill has received some publicity after a trial suggested that it can dramatically reduce the risk of coronary heart disease and offer the promise of significantly increased life expectancy (BMJ 2003; 326: 1419–24). Perhaps if I introduced these patients to my frail old lady they might reflect that improving the quality of life is more important than increasing its duration.
Mike Fitzpatrick e-mail: [email protected]
1340
utumn is back to school time. My children get fancy new backpacks, insulated lunch sacks, and I usually throw in a drug company pen for good measure. This is a familiar ceremony around our house, since I frequently give these pens to my children if they are disconsolate or need a nice pen for school. The nicer quality drug pens are stashed in a plastic candy jar. These are the ones that are heavier, shinier, or somehow more notable in appearance than the cheaper ones. The jar was also a drug company gift, but I have long since disposed of the candies it originally contained. My daughter looked at several likely candidates that had eye and hand appeal, but bypassed them in favour of a garish plastic pen adorned with a bright yellow fire hydrant at the end of the clicker to signify the many fires of indigestion that the gastric acid suppressor could put out. After my daughter had her turn, I couldn’t let my son get short-changed so I repeated the process with him. He selected a pen with a burnished metal barrel of deep blue emblazoned with the name of an antidepressant. Perhaps it signified the myriads of people who could be saved from feeling blue by the drug, or maybe the manufacturer thought it would look snappy in the pocket of the doctor’s white coat, or that my fourth grader could swap it for a really awesome Pokemon card. My receptionist’s son is in college and the campus intelligence I received from this source indicated that better quality Viagra pens were being sold on college campuses for $50. I suspect that the market for Viagra pens and Pfizer stock have both corrected by now, but you never know. I have stealthily observed that our Viagra sales representatives have different qualities of pens. The doctors in my
A
office that these salesmen perceive as their heavy prescribers receive a very solid and impressive metal pen of about US$3–4 in value, perhaps to signify all the unhappy erectile dysfunction suffering they were going to relieve. The less frequent Viagra prescribers, like myself, only got an ersatz plastic pen that cost about a quarter. When I was presented with this flaccid token of pharmaceutical gratitude, I smiled graciously and said “thank you” but deep inside I wanted one of those more potent pens. Although I surely would have been given one had I requested it, I was too embarrassed to ask for it, just like many Viagra users. I consoled myself silently with the thought, “who really wants a fancy pen with a drug company ad on the side?” A cardiologist colleague was given a fancy Mont Blanc from a pacemaker manufacturer. I know I can’t even aspire to achieve that level of drug company fawning. My children do not know this, but I have another top secret stash of drug company pens. These pens are special because they have the names of drugs that have been removed from the market. As soon as I learn the Food and Drug Administration is recalling a drug, I quickly check my office to see if I have a pen that bears the name of the drug that has been honoured with this dubious distinction, and I induct it into my “Recalled Drug Hall of Fame”. The last honoree was cerivastatin. What I’ll eventually do with these relics, these plastic mementos of failed therapeutics, I haven’t decided. Perhaps in my old age I can open a museum. Every time I add a pen to this elite collection, I remind myself of the truth of the old adage, “you have to use the new drug while it still works”. Larry Greenbaum
THE LANCET • Vol 362 • October 18, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.