Garth Rattray | Follow-up visits are essential

A patient was well overdue for her routine follow-up and review of her medications. Before I had an opportunity to ask how she was doing, she asked me if, in the future, I could simply keep repeating her prescription. She went on to reveal that she posed the same question to her husband, and that he replied, “The doctors have to live”.

She was on long-term medications for hypertension and dyslipidaemia. Although the script was written to last for six months, she had a friend with pharmaceutical connections who was able to get her prescription repeated for over a year. Eventually, an astute pharmacist realised that this was being done and did the right thing by instructing the patient to visit her doctor to get a check-up along with an updated script.

I know that an indeterminate number of patients would like to have whatever medication(s) they are taking repeated ad infinitum; but this is a very bad idea. Prescribing medications indefinitely, without regularly scheduled reviews of the patient and the medications, conflicts with good prescribing practice and can endanger patients.

Many people hate, and some fear, having to take prescription medications. A plethora of misconceptions surround these drugs. Patients tell me that, if they start taking them, they can never stop. This is not always true. Non-communicable diseases (NCDs) like hypertension, diabetes mellitus, dyslipidaemia, and cardiovascular diseases require long-term treatment because they are usually chronic diseases.

Sometimes, the NCD is secondary to some other problem. In such cases, once the primary problem is addressed, treatment for the NCD may be discontinued. An example of this is a badly overactive thyroid gland. This can cause lipid derangement. If the thyroid problem is treated, the cholesterol can return to normal and may not require long-term treatment. Sometimes people on steroids develop diabetes. If the steroid is no longer required, the diabetes will resolve.

Some other examples include poor nutrition, a sedentary lifestyle, and sleep apnoea. These can all lead to the development of NCDs. In some cases, changes in diet and lifestyle can eliminate the need for medications. But that decision is up to the physician who is treating, testing, and monitoring the patient. A patient should never stop taking medications or attending regular follow-up checks. And relatives or friends should never advise anyone to discontinue taking medications and attending regular checks.

NCDs require ongoing checks on organ function through examination and investigations. These investigations may be blood tests, but sometimes they require imaging and physiological studies to determine if there is a threat to any organ or existing end-organ damage.

Reviewing NCD medications will allow the physician to adjust doses, if necessary, and ascertain if there are any adverse side effects present. Checking on patients often reveals the bane of medical care ... non-adherence.

Non-adherence is the main reason why treatment regimens fail. It also wastes healthcare resources because patients end up needing more serious intervention for longer. World Health Organization (WHO) surveys in developed countries found that about 50 per cent of patients with chronic diseases do not comply with their dosing schedule within the first year.

That sobering and troubling statistic was from a landmark report ( Adherence to Long-Term Therapies: Evidence for Action). Released by the WHO in June 2003, it is a compilation of rigorous reviews of existing studies and was spearheaded by the WHO and its academic researcher, Dr Eduardo Sabaté.

The report quoted a few comparative worldwide figures for non-adherence. “In Gambia, China, and the United States only 27 per cent, 43 per cent and 51 per cent, respectively, of patients adhere to their medication regimen for high blood pressure. Similar patterns have been reported for other conditions such as depression (40 per cent-70 per cent), asthma (43 per cent for acute treatments and 28 per cent for maintenance), and HIV/AIDS (37 per cent-83 per cent).”

When questioned about repeat prescriptions, it was discovered that short refill times of 28 days are too repetitive and harassing for patients. They would be more likely to refill the scripts if they were written for three to six months before needing to be repeated. But then, if a six-month prescription is repeated even once, that would be a one-year time lapse before the patient and the medications are reviewed. That long gap could pose a safety problem for people on medications for NCDs.

Therapeutic failure because of non-compliance occurs for several possible reasons: polypharmacy (taking many medications), complex drug schedules, confusion about how and when to take medications, high costs, fear of possible side effects, side effects and, perhaps most of all, being asymptomatic.

NCD patients without symptoms cannot see their retinal damage, feel their plaques growing and becoming unstable within their arteries, or feel the narrowing of the blood vessels to their brain, heart, kidneys, and feet. Asymptomatic patients cannot feel anything terrible going on in the background until there is profound damage. By that time, intervention is aimed at ameliorating the damage and salvaging whatever function is left.

The time intervals for reviewing and retesting patients with NCDs vary according to the severity of the condition and the degree of control attained. Early in the disease process, a review may be needed in one month. However, for most NCDs, review is required between three and six months. Sometimes, if the NCD is well controlled, the review can be up to one year.

It’s never about the doctor having to live (survive financially), it’s always about the patients needing to live (survive their NCDs).

Garth Rattray is a medical doctor with a family practice and author of T’he Long and Short of Thick and Thin’. Send feedback to columns@gleanerjm.com and garthrattray@gmail.com.