Dr. Andy

Reflections on medicine and biology among other things

Monday, May 09, 2005

Why do you lie to me?

If there is one thing that drives me nuts it is patients who blatantly lie to me. If you aren't taking your medicines, be honest about it. At least I'll understand why you aren't doing well and stop increasing your doses and adding therapies with poorer benefit/risk ratios.

Estelle (name and some details changed to protect the guilty) is a very sick 27 year old. Very sick from her bad asthma. I've seen her 3 or 4 times since coming to Pittsburgh and she is always doing terribly. I've slowly increased her Advair* from the lowest stregnth to the highest, with no effect.

She says she takes her medicine faithfully, but still need albuterol several times a day to control her symptoms.

She has called several times to request more albuterol be called in, indicating she is using it a lot; much more than we'd like. The last time the nurse thought to ask when she had last refilled her Advair prescription.

The answer: June 2004! So for almost a year, this woman has been coming in to my office, reassuring me about how she is taking the medicine and how it "just isn't helping" when she isn't even taking it. As my colleague used to say, "Advair 250/50 doesn't work any better than Advair 100/50 if you don't take it."

Why does she do this? Won't the primary MD prescribe albuterol? Does she want to die?

I don't know, but I know I'm worried. Overuse of "reliever" medicines is associated with fatal and near-fatal asthma outcomes. Regular use of inhaled corticosteroids (ICS) like fluticasone in Advair is associated with protection. But ICS don't make you feel better right away like albuterol does, so patients don't take it regularl.

So I called Estelle and told her what we had found out. She halfheartedly denied it, blaming the pharmacy, but she knew she was busted. I told her (and dictated a letter stating) I would give her a single additional refill of albuterol, but unless she followed up, we'd call in no more refills.

This is a horrible position to be in as an asthma specialist. Either I continue calling in repeated albuterol prescriptions, thereby enabling dangerous, perhaps fatal behavior, or I refuse an asthmatic the medicine she needs should she have an attack. Talk about a no win situation. Luckily Estelle lives in the city, so she has the ED if she has an asthma exacerbation.

I think the best thing is to give fair warning and then demand minimal compliance from the patient.

Several days later, my secretary, who has very severe asthma, came into my office saying how proud of me for writing Estelle the letter. She told me of her own non-compliance at that age and how one doctor had told her she might die from her asthma if she didn't start taking care of myself. Eventually, that doc got through to her and now she takes all her meds and is doing much better.

We'll see if it works for Estelle

*Advair, in which I have no financial interest, is a medicine which combines fluticasone, an inhaled corticosteroid to decrease inflammation, and salmeterol, a long-acting beta-agonist, which decreases smooth muscle contraction, allowing patients to breathe easier. Studies have demonstrated that this combination gives good relief of symptoms without using higher doses of steroids. It is a great treatment for patients with moderate to severe persistent asthma.

BTW, I have no financial interest in this (or other) drug companies, so while I may be wrong, I am honest.


At 3:54 PM, Anonymous ollie said...

Hmmm, pay for advice and not listen to it. Sounds like my calculus students. :-)

At 9:20 AM, Blogger jon said...

Looking at asthma drug info online today while my son coughs I came across this post. Does anyone know a good asthma drug site to help?



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