Thanks for pointing us to an excellent and thought provoking article - should be
read by all doctors, IMHO.
Laurie (Miles)
> -----Original Message-----
> From: GP-UK [mailto:[log in to unmask]] On Behalf Of Leon Geffen
> Sent: 21 June 2007 10:55 am
> To: [log in to unmask]
> Subject: Re: [GP-UK] How dangerous is polypharmacy?
>
> I suggest you read the article from the new yorker a few weeks ago
>
> http://www.newyorker.com/reporting/2007/04/30/070430fa_fact_gawande
>
> Leon geffen
>
> -----Original Message-----
> From: GP-UK [mailto:[log in to unmask]] On Behalf Of Laurie Slater
> Sent: 21 June 2007 12:35 AM
> To: [log in to unmask]
> Subject: Re: How dangerous is polypharmacy?
>
> She is 80. Come to think of it I don't know either. Are you able to share
> them with us? If we get the maths right and extrapolate we might be able to
> give her one of those clocks that counts down the seconds to go ... on a big
> green luminous LCD. (-:
>
> Laurie
>
> -----Original Message-----
> From: GP-UK [mailto:[log in to unmask]] On Behalf Of David Jobson
> Sent: 19 June 2007 21:06
> To: [log in to unmask]
> Subject: Re: How dangerous is polypharmacy?
>
> If she isso up to date and with it, does she really know the NNTs for most
> of what she is taking?
>
> David Jobson
>
>
>
> > At 13:28 17/06/2007, you wrote:
> >>I recently saw an 80 yr lady with DM, hypertension, hyperlipidaemia,
> >>IHD, CCF, CVA, AF, COPD, osteoporosis, OA, pain, myxoedema. She sees a
> >>number of private doctors who all make their evidence based
> >>recommendations and she is now on over 30 prescription medications. We
> >>spent the whole 15 minutes trying to sort out her medication with very
> >>little time for meaningful interaction otherwise. She is an
> >>intelligent woman who is polysymptomatic but not depressed. She
> >>strives for good health and takes responsibility for her actions but
> >>the logistics of trying to organise, obtain, take and monitor this
> >>treatment consumes her whole life.
> >>
> >>We got down to below 30 scripts, but I felt that I had made little
> >>appreciable difference to her wellbeing and that the process in which
> >>we were both engaged was very conflicted. Every ounce of common sense
> >>told me to reduce prescribing, but various professional guidance
> >>(NICE, NSF and
> >>QOF)
> >>tells me otherwise. It is an increasingly common scenario. I wonder if
> >>Vernon Coleman is not correct in his rants about polypharmacy.
> >>
> >>What to do?
> >>
> >>Laurie
> >
> > Some thoughts, for debate if people are interested.
> >
> > Modern medicine keeps alive people who would otherwise have died from
> > their multiple pathology.
> > Modern medicine can harm or even kill people.
> >
> > Your patient appears willing to devote her time, energy and resources
> > to staying alive, almost no matter what the cost.
> > How can you help her achieve her goals?
> >
> > She needs:-
> >
> > Thyroxine or the equivalent
> > Appropriate pain management
> > Appropriate DM care
> > Appropriate IHD care
> >
> > Whether to give Warfarin, Aspirin or nothing for AF in this situation
> > is something that a well informed patient and a careful GP will want
> > to decide together, specialists are not, in my view, usually best
> > placed to have the final conversation with patients in such complex
> > situations. I think there are real doubts about the overall value of
> > warfarin in such a complex situation, but others may disagree.
> >
> > Whether to use statins in this situation in this situation might also
> > be argued, but if no side effects then I would. If there were side
> > effects I would NOT change to any agent not shown, in trials relevant
> > to this age group, to reduce overall mortality, nor would I be likely
> > to agree to prescribing such Rx on the NHS.
> >
> > IF her COPD is drug responsive she will need the appropriate
> > treatment, probably a beta agonist inhaler and tiotropium in my
> > practice, possibly steroids if steroid responsive. Respiratory
> > physiotherapy and rehabilitation have a place, as does domicilary
> > oxygen
> for some patients.
> >
> > Osteoporosis management... If established on a treatment with no side
> > effects and no evident interactions, why negotiate to stop it? If not
> > yet on treatment you are well placed to discuss pros and cons.
> >
> > Depression... You say she's not depressed. She ought to be. Not
> > being depressed in this situation, when she seems to have chronic pain
> > and faces imminent death but seems willing to devote everything to
> > staying alive sounds like denial.
> >
> > Finally, no matter how many different medications she's on, if you can
> > reduce her medication to twice daily medication sessions (perhaps
> > occasionally inhaler use in between) you will have done a great service.
> > Quality of life, concordance and safety are all likely to improve.
> >
> > Or of course, ignore all this, which naturally is just a point of view
> > ;-)
> >
> > Julian
>
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