Garth Rattray | Why some medications fail

Many years ago, I saw a middle-aged female patient for, what appeared to be, a fairly active postnasal [sinus] drainage. I prescribed medication for her, and she was for review in two weeks. However, after one week had passed, she returned to complain that she was still feeling unwell.

I was seeing a patient, so I asked her to speak with me on the nearby intercom. She went into detail about how sick she still felt. I was at a total loss to explain why the prescription had failed … but then something incredible dawned on me. I calmly asked her, “Have you bought the medication as yet?” There was a very pregnant pause before she replied, “No.”

That was not the last time that I had patients complain without taking their medication(s). What is far more common is patients not taking their medications properly. This becomes a very serious matter when the medications are for serious illnesses like infections or chronic non-communicable diseases (NCDs) like hypertension, diabetes mellitus, and hyperlipidaemia (high [bad] cholesterol). Although we see it often in our practices, it is still disheartening and frustrating to see research showing that about half of the patients with NCDs do not take their [morbidity-reducing and life-saving] medications as prescribed.

Not taking prescribed medications at all or improperly used to be referred to as ‘non-compliance’. But compliance is when someone obeys a command when forced to do so or blindly. That term has fallen out of favour because we want patients to participate in the decisions regarding their own health. So now the term is ‘non-adherence’. Adherence occurs when people choose to do something that will benefit them. To that end, we try to explain why the patient needs to take the medication in the hope that said patient will decide to adhere to the prescription for his or her own good.

NON-ADHERENT

In spite of our best efforts, many patients are non-adherent simply because they forget to take their medications. To counter that common problem, we suggest using a pill box and putting the medication(s) where the patient will see them. About half of the other non-adherent patients intentionally skip doses. Some intentionally skip doses to ‘stretch out’ the medications so that they will last longer (and so cost less. Others intentionally skip doses because they fear becoming “addicted” or “dependent” on them.

But addiction is defined as “a chronic, relapsing disorder characterised by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control”. And dependence refers to someone “feeling like they cannot function normally without taking a substance. Dependence can be physical or psychological and can have many negative effects on someone’s life”.

It is, therefore, clear that ‘addiction’ and ‘dependence’ have nothing whatsoever to do with most prescription medications and have nothing to do with prescriptions for NCDs. The other worry expressed by many patients is that if they take medications, they will need to stay on them for life. The fact is this: if the condition is a lifelong problem, the medications will likely be a lifelong necessity.

Skipping medications has potentially serious repercussions. If antibiotics are skipped, the bacteria are given the opportunity to develop resistance, which is bad for the patient on treatment and for anyone else to whom the infection may be transmitted. In other words, people who are in the habit of skipping antibiotics contribute to the foreseen antibiotic apocalypse that is on the horizon.

SIDE EFFECTS

Another common belief is that “all medications have side effects”. The accurate statement is that medications [MAY] have side effects. The fairly recent direct to consumer marketing (DTC) employed by many drug manufacturers has precipitated a lot of anxiety and caused many patients to fear taking any medications. The problem is that when a medication is marketed using DTC, there is a responsibility to mention every single possible side effect no matter how improbable.

The drugs used in chemotherapy, anticoagulation, antipsychotics, immune modulators (biologics), and opioids carry a significantly higher risk of possible side effects than medications for the common NCDs (hypertension, diabetes, and hyperlipidaemia). The risk of serious side effects from taking these medications varies depending on the specific medication, dose, and individual patient factors.

When it comes to the anti-hypotensive meds, hypotension (low blood pressure) carries the greatest possible risk of up to five per cent. Otherwise, possible side effects include electrolyte imbalances, kidney problems, angioedema (swelling of face, lips, tongue), cerebro-vascular issues, heart failure, or bad allergic reactions. These range from 0.1 per cent to between 0.5 and two per cent.

For diabetic medications, hypoglycaemia (low blood sugar) carries the greatest risk of two to 10 per cent. Other possible side effects include lactic acidosis, cardiovascular events, kidney problems, liver problems, pancreatitis, and allergic reactions. The general risk percentages are from 0.1 to two per cent.

Some cholesterol-lowering medications may cause muscle damage, liver problems, kidney problems, several questionable effects on the central nervous system, or allergic reactions. Overall, the occurrence is 0.5 to two per cent. Healthcare personnel are on the lookout for possible side effects of prescribed medications and can counter them. It is therefore exceedingly rare to sustain serious damage or die from your NCD meds.

However, your risk of developing very serious and deadly ‘side effects’ from uncontrolled hypertension, diabetes, or hyperlipidaemia is 100 per cent! Therefore, if lifestyle changes and [perhaps] approved alternative treatment fail to control your NCDs, take your medications properly. The number-one cause of treatment failure is non-adherence.

Garth A. Rattray is a medical doctor with a family practice. Send feedback to columns@gleanerjm.com and garthrattray@gmail.com.