In my practice, computers replace brown paper bags

Concerned about drug interactions in older patients? Here's a convenient way to head off potential problems.

By Arthur D. Silk, MD
Internist/Garden Grove, CA

As a Medical Economics article pointed out last year, many senior citizens take a fistful of prescription drugs each day.* When you add the over-the-counter products and nutritional supplements these folks also take, the total can exceed 20 pills. The potential for interactions is enormous.

That's why I consider it so important to track what my patients are swallowing. When a 69-year-old man with diabetes and chronic atrial fibrillation first came to see me, for instance, he told me he was on digoxin and Lanoxin, and he had no idea they were the same medicine. Fortunately, we noticed the double dose before it became toxic.

How does this happen? Often, through miscommunication from doctor to doctor or emergency department to doctor. But that's not the only problem. I've noticed a trend among drug makers to market the same pharmaceutical under more than one name. The antidepressant Prozac, for example, is also marketed under the name Sarafem for premenstrual dysphoria. Buproprion is sold as Wellbutrin for major depression and Zyban for smoking cessation.

Substitutions introduced by pharmacy benefits managers can also cause problems. Although the managers are supposed to get permission to substitute, they don't always.

It would be nice if we could count on the computer at the neighborhood pharmacy to pick up on this when a prescription is filled, but obviously we can't—especially when patients use mail-order pharmacies or see several doctors. So I've been trying to devise a suitable way to check up on what my patients are taking.

At first I tried the standard brown bag approach, asking patients to bring in all their pills, including the nonprescription ones. But it proved impractical. Mine is a solo practice that caters to a Medicare population, and it took my patients longer to unload and load their bags than Medicare thinks I should devote to an entire Level 5 visit for complex medical problems.

One 78-year-old retired teacher brought in four grocery bags full of pills! I could have seen two or three less-complicated patients in the time it took to go through them all, since I don't have a nurse or physician assistant to handle this task for me.

Next, I asked patients to bring in a handwritten list each time they visited. Though this worked better, the results still weren't satisfactory. I got lists written on the backs of envelopes or old menus, often illegibly. Even if I could read the writing, it was sometimes hard to recognize the drugs, because the names were badly misspelled. Nor was I confident that the dosage or frequency was right.

Then it occurred to me to ask my technology-literate patients to keep a list on the computer and bring me printouts. Updating the list would take only a few keystrokes, and they wouldn't have to reconstruct the list for each visit. I ask my patients to list the name of each medicine—generic or brand—the strength, and the time or times they take it each day.

I also ask them to write what they think the medicine does for them. I have them note the name and specialty of the prescribing doctor—which may afford me some measure of protection in a malpractice suit, if I ever need it. I hand them a form to take home, so they can remember the information I need.

Cooperative patients bring the list to each visit. I scan it for obvious mistakes and compliance, then make it part of the chart. The lists get increasingly accurate with each visit, as patients add items they forgot earlier.

Of course, not all of my patients do this—even those who agree it's a good idea. So far, only half who can do it have been willing. Still, among that half we've found patients on two identical NSAIDS sold under different names, or two diuretics when only one was needed, or taking as many as three calcium channel blockers, among other problems.

This isn't a perfect system. Even when patients want to comply, they can forget. But I'm happy for the number of potential medical problems we've prevented, by catching drug-drug or drug-vitamin interactions before they caused my patients serious harm. When this system works, it works beautifully.

*"Thank God for noncompliance—this time at least," May 21, 2001.

Letting the computer keep track

Here's an example of a medication chart kept by a 66-year-old man with ASHD, dyslipidemia, arthritis, and BPH.

Arthur Silk. In my practice, computers replace brown paper bags.

Medical Economics

2002;2:56.