[MOL] Here's what the Doctor should know about the drugs you take! [00525] Medicine On Line


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[MOL] Here's what the Doctor should know about the drugs you take!



Before You Start a New Drug: Questions Care Providers Need to Ask Themselves and Their Patients

A. What is the patient taking?

It is important to take a complete medication history from your patients. If possible, have them bring all medications they are taking into the office or pharmacy for identification. Record the complete medication list at every clinic visit, to remind yourself and the patients what they are taking.

  1. Prescription?
    Find out if the patient is getting prescription medications from more than one care provider, or from more than one pharmacy. Fragmented care is very common among HIV-infected patients.

  2. Non-prescription?
    Many patients forget to tell the doctor, nurse, or pharmacist about their non-prescription medications. These can be extremely important causes of drug toxicity, and are occasionally involved in drug interactions.

Specific categories of drugs to ask about include:

  1. Over-the-counter (OTC) drugs (antacids, analgesics, H2- antagonists, etc)
  2. Health foods and vitamins
  3. Alternative medicines (herbal, Chinese, etc.)
  4. Underground prescription and investigational drugs (purchased through Buyer's Clubs)
  5. Drugs of abuse, illicit drugs
  6. Investigational drugs obtained through study participation

B. Can you (and the patient) identify what drugs the patient is taking?

It is a good idea to visually inspect all medications the patient is taking, and (perhaps with the assistance of a pharmacist), identify each medication from reference guides such as the Physicians Desk Reference. Be certain that what the patient is actually taking, and what they think they are taking, is one and the same. For example, there have been reports of pharmacies mistakenly filling prescriptions for ritonavir (Norvir®) with zidovudine (Retrovir ®). Virammune ®(nevirapine) and Viracept ®(nelfinavir) are equally confusing.

C. How confident are you that the patient is taking the drugs as prescribed?

  1. How to ask about adherence
    Partial adherence is extremely common. Evaluating drug interactions requires knowledge of how much medication the patient has taken, and when. A neutral approach to adherence history is preferred. Questions like "Have you taken all the medications I prescribed?" are usually unhelpful. A preferred statement would be: "Many patients find it hard to take all the medications they are prescribed. Have you found it difficult to take all your medicine, and do you find yourself missing doses?"

  2. How important is non-compliance, underdosing, overdosing, altered dose intervals?
    For some drugs, like HIV protease inhibitors, good adherence is probably very important in assuring long-term anti-HIV activity and preventing resistance. In addition, increasing or decreasing drug dose, or increasing or decreasing dosing interval, may have a major impact on drug interactions. The impact can be significant, as most drug interactions are a direct function of drug concentration over time. This is especially true for metabolic inhibition interactions, and pharmacodynamic interactions.

  3. What are some strategies to increase adherence with the regimen?
    A thorough understanding of HIV therapy, including the importance of good adherence and the dangers of poor adherence, is an important basic tool to increasing adherence. In addition, many pharmaceutical manufacturers and patient advocacy groups may supply adherence aids such as timers, diaries, calendars, and pill boxes. Learning the patient’s daily routine and incorporating dosing cues into that routine may also increase adherence. As a healthcare provider, the construction of a regimen using the minimum number of agents, using combination products (i.e., Combivir®), and selecting drugs which are given once- or twice-daily may be useful, if clinically warranted. It is also important to provide positive feedback for a successful response.

D. Does the patient understand the effects and side effects of all the medications they are taking?

It is a good idea to go over the important beneficial effects and side effects of every medication the patient is taking. In a busy clinical practice, a pharmacist, nurse, or any knowledgeable personnel can facilitate this, but it is important that the care provider counsel patients about what they can expect and what they need to know, when starting a new medication. For example, a patient initiating therapy with ritonavir (Norvir®) should be extensively counseled on the gastrointestinal adverse effects that are likely to occur, especially during the first few weeks of therapy. Such information can greatly increase adherence to the regimen. Discussions related to new medications should be documented in the patient record.

Many of the medications used in the management of HIV infection have overlapping side effects. Some common examples are listed below. Patients should be counseled about the signs and symptoms of adverse effects (such as numbness and tingling in the extremities with peripheral neuropathy), and informed to contact their healthcare provider if any of these symptoms occur.

Pancreatitis

Renal dysfunction

Bone marrow suppression

Peripheral neuropathy

Clinically significant or dangerous drug interactions should be included in any counseling or educational activities related to a new drug.