Rule 1: Have “Brown Bag Sessions” with Your Primary Doctor; Fill Out a Drug Worksheet. It is impossible to overemphasize the importance of this first and most crucial step in preventing adverse drug reactions. Whenever you go to a doctor you have not previously seen or to one with whom you have never had a brown-bag session, gather all prescription and over-the-counter drugs and dietary supplements in your medicine cabinet or anywhere else and bring them to the doctor so that a list can be made and you can start to fill out a Drug Worksheet. The purpose of the Drug Worksheet is for you and your doctor (or doctors) to keep an ongoing record of all drugs you are using, the purposes for which they are being used, adverse reactions, whether the drug is working, and other information essential to the safest and most effective use of these products. Doctors should never prescribe a drug or renew a prescription, nor should you be willing to get a new prescription, without full, up-to-date knowledge of all drugs already being taken or likely to be taken. Before your brown-bag session with the doctor, your pharmacist may help you to fill out some of the blanks on your Drug Worksheet. Once you have brought in all the drugs you are taking, ask your doctor to help you fill out the Drug Worksheet. You will probably be able to fill out more of the information concerning over-the-counter drugs yourself, since doctors often do not know that you are taking them or for what purpose. The doctor will be able to help you to fill out most of the information concerning prescription drugs, at least the ones that he or she has prescribed for you. Explanation of Items on Drug Worksheet a. Name of drug, of doctor who wrote the prescription, and date drug was started or the dosage changed: Drugs should be listed by both brand and generic names, since both are commonly used. All drugs prescribed by all doctors should be listed. Over-the-counter drugs and the amount of alcohol, tobacco, and caffeine used should also be indicated. There are many dangerous interactions between drugs and between drugs and alcohol, so this information is extremely important in avoiding adverse drug interactions. b. Purpose of the drug: Identify the reason for which each drug is being taken. Often, because physicians are frustrated at not being able to do anything else for the patient, or sometimes because the doctor believes that the patient will not be satisfied unless a pill is recommended, prescriptions are written without a valid medical reason. In one study, patients reported that one out of every four times (25.4%) they received a prescription, they were not told the purpose of the drug being prescribed.1 c. Dose, frequency of use, and duration of use: It is important to know what the dose is, how often it is supposed to be taken, at what hours, and for how long. d. When the drug should be stopped or the need for its use reevaluated: For any drug, new or old, you should assume that it should be used for as short a time as possible unless there is evidence that its continued use is necessary. An exception to this is the use, for a prescribed period of time (even if you are feeling better), of antibiotics. Evaluation at least every three to six months of the need for each drug being used will reduce the number of drugs being taken. For some drugs, such as tranquilizers, sleeping pills, anti-depressants, and others, much more frequent reevaluation is necessary. e. Important possible adverse effects of the drug: Because many of the most serious perceptible adverse effects of drugs are often wrongly attributed to such things as “growing old” (such as falling, memory loss, depression, and many more), it is important for patients to know about the adverse effects of the drugs they take so they can recognize them and report them to the doctor. In one study, researchers found that 37% of documented adverse drug reactions had not been recognized by patients and reported to their doctors, and that the majority of these patients had not been informed about possible adverse drug reactions by their doctors.1 f. Important possible drug and food interactions, especially with over-the-counter drugs, and diet recommendations: Ask your doctor which foods and other drugs taken along with your drug can interact and cause adverse effects, and ask for dietary recommendations. g. How you are actually taking the drug: Always be straightforward with your doctor about whether or not you are taking your medicine and how often. Do this even if you had no defined reason for stopping. This is important because not giving your doctor this information can lead to mistaken conclusions about what dosage or drugs work. h. New problems or complaints noticed by the patient, friends, or family since any of the drugs listed on the worksheet have been started: As mentioned above, patients themselves often do not notice a change, especially older adults who are inclined to blame many of their problems on aging. Friends and relatives are often the first to notice adverse drug reactions, especially ones that affect thinking or mood. An additional difficulty is that patients are often reluctant to tell their doctors that something the doctor did to try to make them better actually made them worse. The safest assumption is that any worsening of a patient’s condition or any new symptom that develops after a drug is started is an adverse drug reaction until proven otherwise. i. In the judgment of you, your family, and your doctor, is the drug working? Have the purposes for which the drug is being prescribed (as in [b]) been achieved?
Rule 2: Make Sure Drug Therapy Is Really Needed. Often, drugs are prescribed to treat situational problems such as loneliness, isolation, and confusion. Whenever possible, nondrug approaches to these problems should be tried. These include hobbies, socializing with others, and getting out of the house. When a person is suffering from an understandable depression after losing a loved one, for example, support from friends, relatives, or a psychotherapist is often preferable to drugs such as antidepressants. (See discussion on the proper use of antidepressant drugs for depression.) Nondrug therapy, such as weight loss and exercise, is preferable to drug therapy for such problems as mild high blood pressure and mild adult-onset diabetes. (See discussions of high blood pressure and diabetes.) Increasing fiber and liquid in the diet is preferable to using laxatives (see discussion of diarrhea). For swollen legs due to “bad” veins in the legs (not due to heart disease), wearing support hose is less expensive, safer, and probably more effective than taking heart pills or water pills. Drugs should rarely be prescribed for anxiety or difficulty sleeping, particularly in older adults. See our discussion of this problem and nondrug solutions. A last category of “disease” for which drug therapy is rarely, if ever, appropriate is drug-induced disease or adverse drug reactions. The proper treatment for drug-induced parkinsonism is not a second drug to treat the problem caused by the first drug, but, rather, stopping the use of the first drug. For any condition, always talk to your doctor about whether the selected drug may cause problems (adverse effects) worse than the disease being treated. A common example of this is the extraordinary overtreatment of older people with slightly high blood pressure but without any symptoms of or problems caused by high blood pressure. (See guidelines for treatment of high blood pressure.) In most cases, treatment will make the person feel worse, with no evidence of any benefit. Always consider the seriousness of the condition that your doctor is considering treating, and try to make sure that the treatment is not worse than the disease. The guiding principle is to use as few drugs as possible, in order to reduce adverse reactions and increase the odds of properly taking the drugs that are really necessary.
Rule 3: If Drug Therapy Is Indicated, in Most Cases, Especially in Older Adults, It Is Safer to Start with a Dose That Is Lower Than the Usual Adult Dose. More generally, start with as low a dose as possible. In other words, “Start low, go slow.” A lower dose will cause fewer adverse effects, which are almost always related to dose. In the elderly, some experts suggest starting with one-third to one-half the usual adult dose for most drugs and watching for side effects, increasing the dose slowly and only if necessary to get the desired effect.
Rule 4: When Adding a New Drug, See If It Is Possible to Discontinue Another Drug. If your doctor is considering adding a new drug, this is an opportunity to reevaluate existing drugs and eliminate those that are not absolutely essential. The possibility of an adverse drug interaction between the new drug and one of the old ones may lead to discontinuing or changing the use of a drug.
Rule 5: Stopping a Drug Is as Important as Starting It. At least every three to six months, regularly review with your doctor the need to continue each drug being taken. For many mind-affecting drugs, such as sleeping pills, tranquilizers, and antidepressants, and for antibiotics, this reevaluation should be more frequent and sooner. The prevailing principle for doctors and patients should be to discontinue any drug unless it is essential. Many adverse drug reactions have been caused by continuing to use drugs long after they are needed. Many drugs such as antidepressants, sleeping pills, tranquilizers, and others that are prescribed for an acute problem are not needed beyond a short period and cause risks without providing benefits. Slow and careful weaning off these drugs may significantly improve the user’s health. In addition to considering whether to stop the drug, you and your doctor should discuss the possibility of lowering the dose. As mentioned above, an exception to this is the use of antibiotics for the prescribed period of time, even if you are feeling better before having finished the prescribed dosage.
Rule 6: Find Out If You Are Having Any Adverse Drug Reactions. If you develop any of the following reactions after beginning to use any drug, contact your doctor. Ask if you really need a drug in the first place and, if you do, whether a safer drug can be substituted or whether a lower dose could be used to reduce or eliminate the adverse effect. This web site lists widely used drugs that can cause each of these adverse effects. • mental adverse drug reactions: depression, hallucinations, confusion, delirium, memory loss, impaired thinking, and insomnia • nervous system adverse drug reactions: parkinsonism, involuntary movements of the face, arms, and legs (tardive dyskinesia), dizziness on standing, falls (which can sometimes result in hip fractures), automobile accidents that result in injury because of sedation, and sexual dysfunction • gastrointestinal adverse drug reactions: loss of appetite, nausea, vomiting, abdominal pain, bleeding, constipation, and diarrhea • urinary tract adverse drug reactions: difficulty urinating or loss of bladder control (incontinence) If you or a relative or friend have any of the above problems or develop other problems after starting a new drug and are taking any of the drugs listed under the respective problem, notify your doctor or tell your friend or relative to notify his or hers. Another way to identify possible adverse drug reactions you may be having is to look up the name of your drug using the search function on this site. Then scroll doown to the section in the drug profile containing details on adverse reactions caused by the drug. The remaining rules for safer drug use (or nonuse) were compiled from a number of lists, but particularly from the World Health Organization’s General Prescribing Principles for the Elderly.2, 3, 4 These rules, however, apply to all ages. All doctors and patients involved in drug therapy should know them.
Rule 7: Assume That Any New Symptom You Develop After Starting a New Drug May Be Caused by the Drug. If you have a new symptom, report it to your doctor.
Rule 8: Before Leaving Your Doctor’s Office or Pharmacy, Make Sure the Instructions for Taking Your Medicine Are Clear to You and a Family Member or Friend. Regardless of how old someone is, the chance of adverse reactions is high enough that at least one other person—a spouse, child, or friend—should know about these possibilities. In the presence of such adverse reactions as confusion and memory loss, this is especially critical. For older adults, the complexities of drug use may be greater, especially for people taking more than one drug and people with physical or mental disabilities. In these cases, it is even more important to inform another person about possible adverse drug reactions. Ask your doctor to make sure that the label on the drug states, if at all possible, the purpose for which the drug is being used. This is especially important when you are using multiple drugs but is always important as a way of increasing your and your family’s or friend’s participation. All information concerning the proper use of the drug should also be on the label. In addition to the label, you should get a separate instruction sheet and have it explained to you.
Rule 9: Discard All Old Drugs Carefully. Many people are tempted to keep and reuse drugs obtained in the past, even though their condition has changed. Additional drugs used may make the earlier drugs much more dangerous. In addition, you may be tempted to give drugs, such as antibiotics, to a friend or relative who you believe may benefit from them. Resist these temptations and avoid further problems caused by using outdated drugs by throwing them away when you are done with your course of therapy.
Rule 10: Ask Your Primary Doctor to Coordinate Your Care and Drug Use. If you see a specialist and he or she wants to start you on new medicines in addition to the ones you are on, check with your primary doctor first—usually an internist or general or family practitioner. It is equally important to use one pharmacist, if possible.
Ph.R GAURAV TANEJA
