When Prescription Practices are the Problem in Patient Care

About 40 percent of the inpatients I, as an internist, see on a daily basis are over age 80. They typically have chronic inflammation and multi-organ system dysfunction, both acutely and chronically. They are on multiple medications, which individually has some amount of evidence substantiating its use as per randomized controlled trials. The reality, however, is that these medications are very often the cause of the clinical problem to begin with.

Furthermore, the realities of clinical medicine are more complex than the rather idealized world often represented in clinical trials. My point is twofold: first, the medications themselves are a toxic burden on the patient; and secondly, there is often no evidence substantiating the uses of common medications in the extremely complex scenarios we routinely encounter, especially in patients over age 80 with acute-on-chronic multi-organ system dysfunction.

I use proton pump inhibitors in patients with DKA, burns, in critical care, active or recent upper gastrointestinal bleed, and that's about it. Statins seem to have no inpatient usefulness other than for acute coronary syndrome. A recent non-randomized trial shows that simvastatin, but not atorvastatin, was associated with reduced all-cause mortality, but no conclusions can be drawn about this class of drugs overall with regards to inpatient use. Benzodiazepines, NSAIDS, and narcotics should be used judiciously. Corticosteroids need to be titrated off, especially in decompensated pulmonary patients with healthy adrenal glands. And antibiotics should not be used to treat lab values - too often they are administered due to elevated white blood cell counts in the absence of clinical signs of infection.

Administrators and health systems analysts should be aware of sloppy medication prescription which can lead to prolonged hospital stay, iatrogenic complications, impaired immunity, and significant clinical deterioration. On daily rounds, a pharmacist should be present, and recommend discontinuation or titrating down certain potentially problematic medications.
Of course there are some medications which are totally harmless and which, if anything, can promote healing or prevent illness - inexpensive medications such as probiotics, vitamins, minerals, and prophylaxis of deep vein thrombosis in patients with no bleeding risk.

Besides removal of unnecessary and harmful medications, prescription practices should be more conservative than what I see currently in the hospital. There are no randomized controlled trials evaluating medications in octogenarian and nonagenarian patients with chronic heart, lung, kidney, and brain disease. Yet these patients are routinely given medications as if there’s no risk involved. But when it comes to pharmaceutical medications, less is more. I’ve seen more problems caused by medications than illness, and implausibly, there is evidence that medication errors and adverse events are the primary cause of death in the United States today. All healthcare workers and administrators need to be vigilant when it comes to medications.

For more on Dushyant Viswanathan and our other Practice Notes bloggers, click here.